September 5, 2013

The Emotional STD

Suicide is the third leading cause of death among young people ages 15 to 24.

AS A DOCTOR, I CAN PROBE, CULTURE, prescribe antibiotics, and aggressively treat and track contagious STDs. But depression is different. It’s more elusive, yet equally, if not more, dangerous. It can come and go, or it can settle in, making itself so comfortable in an adolescent’s psyche that it’s nearly impossible to extricate. There, just as many STDs do, depression causes permanent damage that may not become apparent for years. To many teenagers, depression can make them feel as though another entity has moved into their body, taking over everything they think, feel, and do.

For the thousands of teens I’ve treated and counseled, one of the major causes of depression is sex. I consider it an STD with effects as devastating as—if not more—HPV, chlymadia or any other.

Just ask any doctor, therapist, or teacher who works closely with teenagers and they’ll tell you: Teenage sexual activity routinely leads to emotional turmoil and psychological distress. Beginning in the 1970s, when the sexual revolution unleashed previously unheard-of sexual freedoms on college campuses across the country, physicians began seeing the results of this “freedom.” This new permissiveness, they said, often led to empty relationships, to feelings of self-contempt and worthlessness. All, of course, precursors to depression.

Teens are particularly vulnerable to the negative effects of early sexual experience because of the intense and confusing array of emotions they’re already experiencing. Adding sex to the picture only makes those feelings more intense and more confusing.

Like most STDs, depression remains hidden and underdiagnosed, even though its prevalence among our teenagers has skyrocketed in the past 25 years, paralleling the rise in STDs. We don’t know exact numbers because so many of its victims can’t put a name to their feelings, while too many adults pass off depressed behavior in teenagers as part of “normal adolescence.” Other teenagers are so depressed they lack the energy or desire to seek help. For while physical pain drives patients to physicians, emotional pain keeps them away.


Still, the numbers we do have on depression in teens are terrifying. According to Dr. John Graydon, professor of Psychiatry and Neurosciences at the University of Michigan, one in eight teenagers is clinically depressed and most teens’ depression goes undetected. Because the rates of completed suicides among adolescents have skyrocketed 200% in the past decade, suicide now ranks as the third leading cause of death in teenagers, behind accidents and homicides (both of which may involve depressed adolescents, who often drink and engage in violent behavior to anesthetize their depressed feelings).

Also frightening is the fact that teens today are more likely to succeed in killing themselves when they try. One study found that completed suicides among 10- to 14-year-olds increased 80% from 1976 to 1980 and 100% for 15- to 19-year-olds.From 1980 to 1997, the rate of suicide increased 11% in all 15- to 19-year-olds, 105% in African-American teen boys, and a startling 109% in 10- to 14-year-old children. Even more sobering is the fact that for every adolescent who succeeds in committing suicide, 50 to 100 attempt it. In fact, a 1995 study found that a staggering 33 out of every 100 high school and middle school students said they’d thought of killing themselves.

One-third of our adolescent population has thought of killing themselves!

This statistic terrifies me, as it does countless parents, teachers, and grandparents in the country. Indeed, many experts on adolescent suicide and psychiatric illness refer to this dramatic increase as “a national tragedy.”And I strongly believe, as do many of my colleagues, that the situation is much worse, that depression is highly underdiagnosed in teens. The bottom line is that depression has invaded millions of our teens. And that’s just what we see on the surface.

I believe even more strongly that there is a correlation between the explosion in sexual activity and the epidemics of STDs and depression in our teenagers. I know this because of what I’ve heard from the thousands of teens I’ve counseled over the past 20 years, and from my own experiences raising four children. What I hear and see is that sexual freedom causes most of them tremendous pain. Now, research is just beginning to show a correlation between teen sex and STDs. One study shows such a strong link between STDs and depression that the authors advised all physicians to screen every teen with an STD for depression. I go one step further—I screen all sexually active teens for depression, STD or not.

We already know that adults with STDs struggle with depression, guilt, and feelings of isolation and shame. And we know from several significant research studies that the breakup of teenage romantic relationships often leads to depression and alcohol abuse. One study of 8200 adolescents, ages 12 to 17, found that those involved in romantic relationships had significantly higher levels of depression than those not involved in romantic relationships. “Something about dating and dating relationships can be toxic to girls’ health,” says Susan Nolen-Hoeksema, Ph.D., a psychology professor at the University of Michigan in Ann Arbor, and an expert in adolescent depression.


Consider Darlene, a 17-year-old patient of mine who sank into a deep depression after her first sexual encounter with her ex-boyfriend. I first met Darlene when her parents brought her in because they were concerned about her behavior. She came at their prompting, but also because she, too, felt she needed help. This is unusual. Most teens (even depressed ones) are dragged in by their parents; few come of their own accord.

During that first visit, I spoke with her and her parents together. Darlene said she preferred that her parents stay in the room at the beginning of our discussion. I was pleased about this, because that showed she had a healthy, open relationship with both of them.

I learned during that first appointment that Darlene had broken up with her boyfriend of two years because she felt, as she said, that she’d “outgrown the relationship.” After a one-month hiatus, she visited him on an impulse. They began talking and, “...before I knew what was happening, we were having sex.” Afterward, she said, she was furious with him, but even more angry at herself. I asked why she felt so angry at herself. She said she’d promised herself that she only wanted to have sex in a deeply felt, meaningful relationship, and that this encounter had happened without much thought or feeling, with someone she had already broken up with. She felt she’d let herself down. “And I didn’t even like him that much,” she said, crying. I was touched to see her father reach out and hold her hand.

At the time, Darlene had told her mother what happened, and together they went to a local pregnancy counseling center where a blood test confirmed she wasn’t pregnant. A few days later, she told her father what had happened and he, too, responded with great sensitivity and compassion. “My mom and dad have been incredible,” said Darlene. “I just don’t get why I’m so upset. They didn’t yell at me or anything. They’ve just been loving me. I can’t believe I was so stupid.”

But in the weeks after the incident, Darlene began withdrawing from both her parents and her friends. She became angry easily. She slept during the day and stayed up late at night—all unusual patterns of behavior for her. She even wanted to drop out of the basketball team, her favorite sport. When her parents saw Darlene’s behavior worsen rather than improve, they brought her in to see me.

During that first visit, I confirmed their suspicion that Darlene was seriously depressed. I hooked her up with a good counselor, but still saw her weekly for the next few months to make sure her depression was lifting. During these months, I realized that Darlene’s depression resulted from unresolved grief related to a deep sense of loss. Loss of her virginity, her self-respect, her parents’ respect, her sense of control over her behavior, and her commitment to herself. She felt so overwhelmed by these losses she didn’t know how to process them and bring them to resolution.

Even though her parents said they forgave her, she didn’t believe them. How could they forgive her when she couldn’t forgive herself?

Many advocates of sexual freedom among teens would argue that she was overreacting. They would say that her real problem was that she valued her virginity and her commitment to it too much. They would say that her parents set her up for depression because they didn’t teach her that sex is normal for kids her age. That if she would only accept this “reality,” she wouldn’t feel any real losses. Finally, they would insist she has nothing to forgive herself for, because she didn’t do anything wrong. And that this is a lesson her parents should have taught her.

But there’s no arguing with a person’s feelings. I believe Darlene’s feelings needed to be acknowledged by an adult whom she respected and to whom she listened. That’s exactly what her counselor, parents, and I did over the next months. We helped her recognize her losses, validate them, and grieve them one at a time. Then we worked to help her to forgive herself. As she resolved each loss and forgave herself, her depression lifted and her “normal” life returned.

Darlene was lucky. She got help before her depression dragged her down so deep she drowned in it. Millions of kids never get that help.


Given stories like Darlene’s, why doesn’t research yet exist linking depression to teenage sexual activity? Three reasons.

First, these twin epidemics have come upon us so quickly there simply hasn’t been time to conduct the studies. But I don’t need to wait for formal studies to affirm what I already see—and my observations are not isolated ones. At pediatric conferences many of my colleagues report the same thing: increased post-traumatic stress disorder in sexually active teens.

I also make the link between sex and depression when I look at our world today from a bird’s-eye view. Consider that life in the United States is relatively stable, with a historically high level of economic abundance. Why should our children be so depressed? And why should so many of them be thinking of killing themselves? Consider the words of Armand Nicholi, M.D., a professor of psychiatry at Harvard Medical School, and an expert on adolescent psychiatric problems: “When future historians study American culture,...they may find it perplexing and paradoxical that during an era of unprecedented leisure time and prosperity, millions of adolescents used psychoactive drugs to alter their feelings and to escape their environment. That each year, during an era of unprecedented openness and frank discussion of sexuality, hundreds of thousands of unmarried teenagers became pregnant and experienced an abortion; and that during an era of unprecedented scientific discovery and opportunity, thousand of adolescents both attempted suicide and succeeded in killing themselves.

Second, in order to conduct studies on the link between teen sex and depression, we would have to start with the hypothesis that, perhaps, indeed there is a link—something that many funding institutions are not willing to do because it opposes more liberal views about teen sex. It’s difficult, if not downright unpopular, today to take a stand that questions whether sexual freedom is good or bad for teenagers.

Third, there’s a great deal of money at stake. If solid research finds that sexual activity in teens leads to depression, it would force many businesses to take a hard look at advertising and the media in general. Businesses would need to look at how sex is used to sell products to the teen demographic group, which today has perhaps the largest buying influence in the history of our economy. To put it simply, the business of selling to teens relies on sexual messages.

We have more experts, more research, and more sophisticated antibiotics, antivirals, and antidepressants than ever before in the history of our country. We understand psychological illness, adolescent behavior, and parenting strategies, yet we’ve never had as many depressed teens and adolescents as we do today. Why is depression so rampant? Why is teen suicide exploding to the point that it’s called a national tragedy? Because our teenagers are hurting and are lonelier than ever before, and because so many stimuli encourage them to find solace for their loneliness and hurt through sex. This doesn’t take their hurt away, it only makes it worse.


Sex and depression present a kind of chicken-and-egg conundrum. Studies find that kids who are depressed gravitate toward sex, since sex acts as a drug, numbing a hurt, filling a void, keeping their minds altered, if only for a moment. But sexual activity also leads to depression.

It’s important here to understand the psychological roots of depression. In teens, depression is a prolonged state of grieving. Normally, one goes through a series of stages in resolving grief: denial, bitterness, anger, sadness, and acceptance. But if, for some reason, you experience hurt or loss and you don’t go through this grieving process, depression can result.

For instance, a teenage boy may feel terrible sadness because he just broke up with his girlfriend, but he doesn’t allow himself to exhibit that sadness for fear that someone (mom or dad perhaps) will notice and make fun of him. Or an adolescent girl who had sex and now feels guilty and confused may not allow herself to acknowledge these emotions, pushing them deep inside where they fester into depression.

This refusal to grieve takes the form of an unpeeled onion. The outer layer is denial that there is any problem, loss, or hurt. This is the most visible layer, and is obvious when teenagers insist I’ve got them figured all wrong, that they aren’t depressed.

Beneath this layer of denial lies bitterness and anger. This anger stems from a sense of loss, and, as we’ll see later, there are numerous losses associated with sex. For instance, there is the loss of self-respect. Even if a teenager is mature enough to recognize this loss, if he doesn’t move past the stage of anger to sadness, where he can grieve this loss, he may become “stuck” in anger at himself.

Or a teenage girl may experience loneliness and a feeling of betrayal after a sexual relationship. If she fails to grieve those feelings properly, she may turn her hurt and anger inward, becoming “stuck” in persistent, unresolved anger and exhibiting harmful behavior, lashing out, stealing, engaging in self-destructive behavior (sex, drugs, alcohol). It may look like rage, but it is also depression.

One classic example of how kids turn this rage inward is the preponderance of body piercing. Punching holes in intimate parts of their bodies, such as their lips, tongue, belly button, or even vagina, sends a message to the world: “I am hurting this intimate part of myself because I don’t like who I am.” When girls pierce the sexual parts of their bodies, their labia and nipples (some so severely they’ll never be able to nurse a baby), they’re saying: “I am cutting on my womanhood. This is anger turned upon the self.”

Beneath this anger often lies sadness. It’s much safer and easier to feel the anger, I tell teens, than it is to feel this sadness. Anger lets energy out, whereas sadness only consumes energy. When you’re sad, you want to be comforted, and too many teens have no one to comfort them. So they keep their sadness to themselves. The hurt stays like a crusted-over abscess on their hearts. Then they become angry with themselves because they’re sad (irrational, yes, but this is teenager thinking), and angry with their family and friends because no one will help them get rid of their sadness or their anger.

At the center of this onion of depression is a hole—the empty space left when that which was so precious and prized is taken away. And, as you’ll see, much is lost when teenagers have sex before they’re ready. These losses are substantial, and can be devastating to the teenage soul.

Loss of self-respect. While many teenage boys claim sex is fun, just as many admit (if given the opportunity) that they lose respect for themselves after a sexual encounter. Some may boast about their sexual exploits and appear on the outside to have gained self-confidence. But others admit to me in private that something changed inside them after they started having sex. They have less self-respect, having given up their sexual intimacy to someone they didn’t care deeply about. Many also struggle with the feeling of loss of control during sex—control of their emotions and control of their bodies. Some teens become annoyed with their female partners for having so much influence over their emotions. Other boys don’t like losing physical control of their bodies during orgasm. Experiencing an orgasm may be embarrassing, particularly if they don’t know the girl well. She may make fun of his penis or ejaculate, or they’re left open to criticism for premature ejaculation, which can be emotionally traumatic. With one disgusted look, a girl has the power to slice his manhood in two. This can have devastating effects on teenage boys, who need a healthy view of their masculinity.

Girls have the potential to feel an even greater loss of self-respect. Part of the problem is that American girls are at times poorly versed in setting physical boundaries. They’ve at times failed to learn to protect their bodies. They’re encouraged to expose every inch of skin they can get away with (think Britney Spears). In doing so, girls are taught that their bodies are not worth protecting. Self-respect issues arise when a girl feels that she’s surrendered control of her body to her sexual partner. If her partner fails to receive what she gives with the respect and awe it deserves, she feels hurt, disappointed, embarrassed, and cheated. When she turns these feelings inward upon herself, the end result is depression.

Loss of virginity. I believe that protecting one’s virginity is hard-wired into our psyches, much as self-preservation is. We don’t train ourselves to respond this way, we are born with it; it’s part of our “fight or flight” response. I believe that preserving our virginity is one part of what we are naturally conditioned to protect, because I have witnessed hundreds of teens grieve the loss of their virginity. Intuitively they know that their virginity is something special. It is private and it is deep.

Proof of the unique and valuable nature of one’s virginity can be seen in kids who are sexually abused. Every young child, adolescent, and teen I have cared for who has been sexually abused hates talking about it. Psychologists and psychiatrists universally accept the fact that most kids who have been sexually abused won’t readily admit that sexual violation has occurred. Teens will admit when their feelings have been hurt or if they have been physically hit, but they don’t want to admit to sexual violation. Why? Because their virginity and their sexuality are separate from their feelings or their bodies. Virginity is more special.

Think about this for a moment. If a girl didn’t value her virginity highly or feel that it was unique, why wouldn’t she openly discuss it? The very fact that something extremely precious has been taken away or violated is one of the reasons kids of all ages keep sexual abuse a deep, dark secret. And the fact that lifelong pain ensues when sexual boundaries are crossed, or when virginity is wrenched from a child in a manner that makes her feel helpless, gives testimony to the incredible value of virginity.

Some might argue that losing one’s virginity voluntarily, as with teen sex, falls in a different category. Certainly it does. But the inherent value of virginity remains the same. If a teen surrenders it voluntarily, she knows that she has given a part of herself that occupies a place of extraordinary prominence in her being. So even when a teen surrenders virginity voluntarily, the loss is still great. And it is still deep.

Finally, many teens want to protect their sexual innocence. This desire stems from a natural one to keep oneself separate, to erect healthy boundaries around one’s body. Teens want privacy—private conversations, private thoughts, private behaviors. This is natural and it is intuitive. So, too, is their sense of privacy surrounding their sexuality. And at the core of this sexuality is their virginity.

But in the midst of the flood of sexualized messages from media, this natural mechanism of privacy preservation is broken down. These media messages train teens to tear down healthy boundaries to their privacy, their sexuality, and their virginity. This can cause tremendous distress and even depression for teens.

Loss of trust. Unless teens have sexual encounters strictly as a form of “fun,” it’s quite possible they may lose trust in their partners. They may begin sex because it is fun, but realize afterward that it involves much more serious feelings than they anticipated. For whenever teenagers expose private parts of themselves (emotionally or physically) during sex, they are exhibiting great trust in their partner. If this results in a pleasant experience, their trust grows, but if it ends badly, their trust is destroyed.

For instance, during sex, a boy may tell a girl she’s lousy, fat, or inexperienced. When this happens, her trust in him that he will make a very serious encounter “safe” is destroyed. Trust is also harmed when teenagers spontaneously end sexual relationships for seemingly no reason, or when they see their partners moving on to other sexual relationships. Or when they hear gossip in the halls about private moments they shared with another.

This loss of trust after the intimate experience of sex can be emotionally devastating. Think about it. Teenagers often seek out sex because they need another person to respond to them consistently, with positive feedback. Take the teenage boy, for instance, who is athletically clumsy, perhaps kind of nerdy. He hesitates to let even his parents see his real feelings because he fears they will ridicule him. He tries to protect himself (quite reasonably) by staying quiet. But he desperately wants and needs to know if he’s got a normal masculinity.

The best way to find out, he reasons, is to have sex with a girl. So he tries it. When he does, he is, in essence, “showing” her his masculinity, strutting before her like a male robin preens and struts before his mate. When she fails to applaud him for his sexual prowess, the shape of his body, etc., then the trust he placed in her is lost. She blew it, just like all the rest, not giving him what he needed, letting him down. Since he’s so egocentric, he reasons that the problem must be with him, not with her. Since she let him down, he really is a jerk and a nerd. He pushes those feelings deep inside him, where they fester, leading to depression.

Loss of expectations. As seasoned researcher and psychiatrist Helene Deutsch wrote in the 1960s, when the sexual revolution was just taking off, adolescents “suffer from emotional deprivation and a kind of deadening as a result of their so-called free and unlimited sexual excitement...the spasmodic search for methods by which to increase the pleasure of the sexual experience indicates unmistakably that the sexual freedom of our adolescents does not provide the ecstatic element that is inherent—or should be—in one of the most gratifying human experiences.” Once they find the sexual experience doesn’t meet their expectations, she goes on to say, teens all too often turn to drugs and show an increasing interest “in sexual perversions,” resulting in what she refers to as the rise of “psychological disaster” in teens.

I call it the result of smashed expectations. For quite often, teenagers build up the sexual experience in their minds, expecting it will fill their emptiness while meeting their needs for love and acceptance and belonging. For instance, teens often use sex as a way to fill the void of loneliness that results from a broken family. All too often, however, those expectations are never met, leaving teens with a grinding emptiness, resulting in frustration, agitation, and depression.

I saw this happen to Andrew when he was 16. He’d been my patient for several years. His mother brought him in because she suspected he was depressed. His grades had dropped and he didn’t want to go to school. Andrew was a talented artist, and his mother noticed that the drawings scattered around his bedroom had dark and gruesome themes. As I began treating Andrew for his depression, he revealed that ever since his father left the family when he was 6, he worried about his mother. “She cries a lot,” he said, and this upset him terribly.

His father was basically absent, and his refusal to send Andrew’s mother money to help pay for his clothes, books, and expenses also upset the boy. Sometimes the father called, sometimes he didn’t. Andrew never knew what to expect. “I just wish my dad would disappear for good,” he said angrily, fighting back tears. The relationship, such that it was, just hurt too much.

When he was 11, Andrew said, an older boy had raped him. The experience left him confused, embarrassed, ashamed, and too afraid to tell anyone. After that, he said, he distanced himself from other boys, preferring the company of girls. At 14, he began having casual sex with girls. “I needed to figure myself out,” he said. Was he gay or was he straight?

But I could see past that. I knew that by having sex with girls, Andrew was really trying to find acceptance of his masculinity, relief from his loneliness, and, quite simply, some love and affection. It was so obvious to me, because when he described what he wanted from sex, he suddenly jumped to talking and crying about his father. About how he was never around. About how disappointed his father must be in him, because otherwise his dad would come around more. Now he was sobbing about how desperately he wanted his dad. His body language regressed, he drew his knees to his chest and hugged them. Then he began asking me over and over why his father did that. “Did what?” I asked.

“Why did he hurt us so bad? What did I do wrong? Why did he leave us?” Suddenly I realized that Andrew was back in his house watching his father pack his things and leave. The tears and facial expressions made me understand that he was in excruciating pain. There it was. The center of the onion of depression, the layers peeled away. He wanted his dad back. He wanted his hugs, his voice, his affirmation that he, Andrew, was okay. Sex, in his mind, was a way to get those things he’d never received from his father.

But sex never delivered. It only made him crazy and eventually depressed. Why? Because Andrew lives in a culture that teaches him that sex is pleasurable, exciting, and full of promise. But the reality is vastly different. In my experience, it’s far more disappointing and frustrating to teens than it is pleasurable. In fact, I’ve asked hundreds of teenage girls whether or not they like having sex, and I can count on one hand those who said they did. Once they confront their smashed expectations, many teenagers feel something is wrong—not with sex itself, but with themselves. So they try harder to make sex “work,” to make sex provide those things they think it should: intimacy, love, trust, acceptance, appreciation of their masculinity or femininity, relief from their loneliness. When it doesn’t work, millions of teenagers, like Andrew, assume something is wrong with them, and turn their anger and hurt inward, resulting in depression.

Andrew was able eventually to understand his feelings and his behavior better. The process took several months, but he learned that sex couldn’t give him what he needed from his dad. To the contrary, it only crushed his sense of self-respect and self-worth. But he also learned he could work on developing good male friendships to alleviate his loneliness. When that happened, he found his sexual desire diminished. He still wanted it, he said, but he didn’t “need” it. He was experiencing healthy sexual desire outside of emotional voids.

Freud called this cycle repetition/compulsion, in which we repeatedly return to certain behaviors such as sex, drugs, or drinking to get something that continually eludes us. When we feel empty, we return to a place in which we hope to find some relief or satiation of our desires or needs. Even when our behavior fails to satisfy those needs, we return again and again, trying harder to find what doesn’t exist.

This is what teenagers often do, turn again and again to sex, hoping to find something that doesn’t exist, sinking deeper and deeper into depression.


One of the greatest losses our teenagers feel is the loss inherent in divorce. When parents divorce, children experience both the physical loss of a parent and the concurrent feelings of abandonment and lack of control. Some teens can handle the death of a parent better than they do a divorce. At least, they rationalize, there is no choice in death.

As I’ve seen in my practice time and time again, divorce loss often propels kids into early sex. Let me explain.

We’ve seen this situation feebly played out on television countless times: Teens feel a large, undue responsibility for the divorce of their parents. It matters not how many times their parents reassure the teen that he or she is not responsible for the divorce. It’s part of how a teen’s mind works. A teenager’s own adolescent self-centeredness and sense of power will negate rational thought, leaving him with pure emotion. As these losses accumulate, some require serious grieving.

Teens who have a good support system and a strong sense of connection with their parents or other adults are able to grieve losses to resolution. They allow themselves to feel their sadness, anger, and hurt, and even talk about them to friends and adults if they believe that their feelings will be respected.

Healthy parents are crucial to this process. We are the ones who provide the safe environment in which teens can feel and resolve their emotions. We need to be on the lookout for losses that occur in our children’s lives so we can help them work through loss and resolve their hurt feelings.

But too often, teens suppress their emotions because they are simply too afraid to let them show at home. As children in our society grow into adolescence, they experience the loss of a sense of being protected, loved, and cared for.

Let’s face it, too many teens are ignored in our culture. Within their own community, it seems everyone is too busy for them. Sometimes their doctor barely has time to talk to them; often both parents work and are too tired to talk when they come home; teachers are stretched thin by overcrowded classes; and psychiatrists have three-month waiting lists. I believe this generation of teens is the loneliest generation in the history of our country. Some parents push them away with the excuse that their kids need to become independent and world-savvy, when, in fact, parents just want their own lives. Kids require energy and patience, which many parents are often too tired to provide.

Too often, kids have no one with whom to figure out life, no one with whom to communicate their anger, sadness, or even the emptiness that life can bring. For teens to acknowledge that they never felt genuinely loved, never experienced healthy intimacy with a parent, and that no one of significance in their life really values them, would cause their world to cave in. Thus, they stuff it. They get stuck in depression. The onion stays unpeeled, an abscess at the center of their soul, waiting quietly for someone to prick it open and drain it.

That’s when teens turn to sex, an action that relieves the momentary isolation, but which often leads to more loss in an endless cycle of emotional angst.


When I counsel teens who are depressed, I try to help them view themselves as whole people who have three dimensions—physical, psychological, and spiritual. I often explain that depression may start in one dimension and then spread to another.

The physical roots of depression generally stem from low levels of various neurochemicals, such as dopamine, norepinephrine, and serotonin. These chemicals play critical roles in the areas of energy, emotions, sensations, and cognition. Nerve endings in the brain release these chemicals, also called neurotransmitters, and they circulate throughout brain tissue until other nerve endings take them back up, similar to the way you suck up soda through a straw. If they aren’t released in sufficient amounts, or are taken up too quickly before the brain has a chance to use them, depression can result.

I try to explain to teens that these physiological changes are completely real and completely out of their control. Just as someone with diabetes suffers from low levels of insulin, those with depression have altered levels of neurochemicals. No one asks for diabetes, no one asks for depression. Sometimes it just happens.

Serious depression can be caused by these imbalances, and for these types of illnesses, drug therapy is often the answer. But for the majority of physically healthy teens, this is not the cause. And unless I see clear signs of acute, long-term depression, we don’t go the drug route.

The second dimension I talk about is the psychological, which I described earlier as “peeling back the onion.” It’s the layers of our subconscious, and as they emerge, these layers define who we are. In the case of depression, our psychological well-being depends greatly on how we handle denial, bitterness, anger, and other emotions as we move toward acceptance of difficult losses. This, as you’ve likely noticed, is a big part of the counseling I do.

What I haven’t talked about yet is the spiritual component. I believe that addressing spirituality for teens is good medicine. And I address it here because the depression that comes from the losses teens feel that are associated with sex are similar to those associated with spirituality. In other words, sex is a spiritual experience.


Teaching teens that there is a dimension of life that we cannot see is easy. Intuitively, they get it. They know that they are deeper than just flesh and bones, and they appreciate it when an adult affirms this. In fact, one of the most delightful aspects of talking with teens is hearing them develop deeper and more abstract thinking. They wonder out loud about the meaning of life and the existence of God. When I ask them about spiritual issues, most love talking about it. It makes them feel smart and adultlike. So I probe and ask questions and they open up.

Most teens admit they believe in a god, either because of upbringing at home or through their church. They have an involvement, a relationship with a “Father above.” Teenagers like the idea of being able to trust in a higher being when they experience difficulty doing things on their own. God becomes their safety net, their power source, the one who takes over when they mess up. I’ve treated many really troubled teens who straightened out their lives and discovered and developed an abiding relationship with God, in whatever way each individual teen perceives this.

But teens who have a vibrant relationship with their God then turn away from it, in response to loss, anger, or hopelessness, for instance, often fall into depression. Philosophers and scholars call this a “spiritual depression.” The teenager recognizes that something important is spurned and is now lost to them. As with other losses, their failure to grieve, or to renew this spiritual relationship, causes them pain. As a physician caring for the entire patient, I must be sensitive to a patient’s perceptions of the world in which they live, how they view the workings of that world, how this creates their own type of religion, and how this all makes sense in their relationship with God. Then, I must be able to help repair those losses if I can. Often, I’ll suggest that teens get counseling not just from psychologists, but also from family and religious leaders.

Many teens describe sex as being spiritual. I agree with them. Sex is sacred and something extraordinary, during which a connection occurs beyond human comprehension. If they believe this is true, then sex indeed is something to be protected and cherished because it affects the spiritual dimension of their lives. Thus, when sex goes awry (or causes pain), that pain affects their spiritual life.


Many healthy, normal teens will experience one or more episodes of brief depression during their adolescence. This happens for a number of reasons, including hormonal fluctuations, major life changes, and small and large losses. Understanding what happens during adolescence (as described in Chapter 10) will help you recognize normal changes in your teens as they occur, and become aware when something is really wrong. For while healthy, emotional upheaval in a teen can mimic depression, there are some major differences you should be on the lookout for.

Age-inappropriate behavior. It’s normal for teenagers to act their appropriate age one day, then act years younger the next, then swerve back again. But when a teenager’s behavior regresses and stays regressed for two or more weeks, there’s cause for concern. For instance, a teen who normally likes going out in the evenings with friends, but stops, instead heading to bed early, may be depressed. Sometimes, depressed teens may even ask to sleep with their parents, particularly if they are experiencing anxiety. This is particularly common in girls who have been sexually assaulted or raped. They’re seeking safety, but they’re also exhibiting regressive behavior.

Emotional outbursts. As teenagers’ hormones fluctuate wildly, it’s normal to see occasional emotional outbursts and temper tantrums. These episodes may last a few days, then suddenly disappear. But depressed teens become angrier and angrier, and show more frequent outbursts that don’t go away. They consistently erupt over small things, becoming irrationally angry and viewing the world only in black and white terms. For instance, while a healthy teen might argue with a sibling over sharing clothes, fighting only for a few minutes, a depressed teen might start crying, screaming, and even flailing her arms and legs. She might devise a scheme to retaliate later on and physically hurt her sibling, clearly displaying anger disproportionate to the conflict.

Sinking self-esteem. It’s normal for a teenager’s self-esteem to drop in early adolescence as they leave behind what they know (childish ways of thinking and acting) and venture into new, unknown areas. They want to behave like grown-ups and think like older teens, but they don’t have a clue how to do that. So they feel insecure because they don’t know who they are or where they’re headed. But as maturity sets in and teens recognize new strengths, they begin liking themselves again and their self-esteem rises. Depressed teens, on the other hand, never like who they are. They see themselves through the dark glasses of depression, and feel negative about everything they think, feel, and do—most particularly, about themselves.

Frequent shifts in friends. Normally, teenagers expand their circle of friends and are part of one, two, or three groups. Although they may leave some friendships behind, they typically carry a few good ones forward while making new friends who have different interests and qualities. But when teens are depressed, they often completely cut their ties with old friends while forging relationships with kids they’d never have been interested in a few months earlier. This sudden transition to completely new friends is a sign of trouble.

Everyday changes. Other warning signs for depression include changes in eating patterns (lack of interest in food, or constant eating), changes in sleep patterns (never sleeping or sleeping all the time), and consistent changes in clothing and grooming styles, including tattooing and body piercing.

Actually, one of the best ways to determine whether your teenager is depressed is to simply ask. Kids who are really hurting, those who feel engulfed in a black cloud, yet who have a decent relationship with you, will tell you how they’re feeling.

Like the cute 17-year-old who came into my office recently for a checkup and cheerfully chattered on about her involvement in sports, choir, and a host of other activities. When I asked if she felt happy about life in general, however, she burst into tears.

For the next ten minutes, she sobbed out the fact that for the past several months she’d been worried that she might be seriously depressed. She’d seen an advertisement on television for an antidepressant medication, she said, and when the announcer read out the symptoms of depression, she realized she experienced every one. We talked for a while and she was clearly relieved by our conversation. As it turned out, she’d been experiencing a mild form of depression that didn’t require medication. Simply talking it out was enough.

This is common in teenagers. I’ve found that teens love talking about themselves and their feelings if they genuinely believe that you can offer them some relief.

So, if you’re ever worried that something is wrong with your son or daughter, start by asking. You’ll be amazed. They may just start talking. And that’s when you need to listen.

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