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“I’m in pain, permanently”.

Adolescent depression is on stage in London: at the KILN Theatre, in ‘The Son’ by Florian Zeller, and at the Royal Society of Medicine, in a timely conference.

I went to see ‘The Son’ by Florian Zeller at the KILN Theatre in London a few weeks ago. It’s the final part of a trilogy — the preceding parts being ‘The Mother’ (focused on a woman’s depression when her children leave the family home) and ‘The Father’ (focused on old-age dementia). I knew that this play was about adolescent mental health, but I didn’t expect it to be quite so moving. It was as though all of a sudden somebody had taken me back to my days as a trainee in the Psychiatry ward.

“He’s not like he was before. Believe me, I don’t know what’s happened, but something has. He’s changed. He … And I’m wondering if … to be absolutely honest with you … I’m even wondering if …”

Anne (played by Amanda Abbington) has just discovered that Nicolas, her son (Laurie Kynaston), has been skipping school for months, so she asks for help from her ex-husband and Nicolas’ father, Pierre (John Light). Anne explains that Nicolas is not the same smiling boy that he was just two years before, before their divorce. Something has changed.

Nicolas’ solution is to attempt a fresh start by moving to his father’s house, where he lives with his new lover, Sofia (Amaka Okafor), and their baby son. But, in the new home, Nicolas feels unwanted. He is not able to explain what’s happening to him, the reason for his self-harming or why he keeps skipping school. When his depression deepens, we find ourselves wondering what could really help him, until a moving and tense dialogue with a psychiatrist puts Nicolas’ parents in the position of making a critical decision about his wellbeing.

At the end of the play I found myself joining in with the standing ovation and clapping as loud as I could. I will try to describe my response to the play, without spoiling it too much for those of you who still want to watch it (it will transfer to the West End in August).

The play brilliantly depicted the family interaction: the impossibility of communication between adolescent and parent. We could see clearly Pierre’s frustration and Nicolas’ desperation, but despite their efforts, my impression was that father and son were not listening to each other.

There are harrowing moments in the play. For example, when Pierre finds out that Nicolas is secretly self-harming. On one hand, Nicolas does not ask for help and does not share with his father his inner feelings. He is completely absorbed in his own pain, his energy is sapped, and he can barely speak. He rarely smiles or relaxes and looks every bit an outsider — even when surrounded by people who love him.

Nicolas, as I soon realized with my clinical hat on, is deeply depressed.

On the other hand, Pierre’s genuine interest in understanding Nicolas soon gives way to his own feelings and concerns. He is in pain as well, the pain of a father who realises that his son is self-harming, but doesn’t know what to do.

From a certain moment in the play, the characters seemed to decide to ‘close in’ rather than reaching out to the other; we could feel their loneliness with heaviness in our heart.

Anne, for her part, looks frozen, as if she is too scared to know what’s really going on. She seems lost, and she even says so.

Overall, the pain takes shape in each character in very different ways, but my impression was that behind their pain there is a constant, overwhelming fear.

When offered psychiatric help in the hospital, Nicolas reaction is “How do you think I’m going to get better if I’m surrounded by people who are much sicker than I am?” This scene reminded me of a doctor that used to work in the Psychiatry ward where I was a trainee. When people in A&E were refusing to be admitted because, in their own words, “there are people much sicker than me here”, she used to reply, “But you are the most severe in this moment, because you’ve just arrived, while the others have already started to recover”.

Mental health problems are always real, even if they have different degrees of severity, and they are heart-consuming not only for patients but also for their relatives. Thus, nobody should feel ashamed of asking for help.

Unfortunately, a lot of people, and especially adolescents, give in to the fear and refuse to seek or receive psychiatric help, or be admitted to a Psychiatric Unit even if it truly necessary. But, as I said in my previous article on treatment-resistant depression, fear comes from the unknown.

Zeller himself, in a recent interview with the BBC about ‘The Son’, said that, “there is something taboo about mental health … there is a lot of shame and ignorance about these problems and I think there are many young people that suffer, and it is important to see that, show that and share that”.

This is also important for parents, who often feel alone in these moments and don’t know how to deal with their children’s suffering.

Early interventions for young people’s mental health.

What can be done to identify and treat depression in adolescence?

This was discussed just last week in a conference at the Royal Society of Medicine (RSM), on “Transforming Children’s Mental Health in Schools: targeted interventions”. This conference brought together medical and educational professionals and parents, to find new ways to take care of school children and young people with mental health needs. Do not worry if you missed it, as similar other events will follow!

Today, one in eight (12.8%) 5–19 year olds have at least one mental disorder, according to a 2017 NHS survey. In particular, 2.6% of adolescents experience depression at any one time, with double the risk in females.

The school might just be the safe and familiar environment where it might be possible to identify and treat these mental health problems.

For example, a project led by Professor Shirley Reynolds (University of Reading) consists of administering a simple screening questionnaire for mood and feelings to school students, in order to identify possible difficulties, followed by the clear question: “Do you want help with that?”. Then, students and parents can choose to go ahead with trained therapists for a few sessions of a psychological therapy called ‘Brief Behavioural Activation Therapy’, which supports and encourages adolescents in “doing more of what is important to them”. This approach has shown some good results in terms of improved depression and increased well-being.

Another exciting research study, currently ongoing at King’s College London, is the MQ’s IDEA project. This study is led by Dr Valeria Mondelli, also president of RSM Psychiatry section. It analyses cultural and family environment, stressful experiences, brain images and stress measurements of people aged 10–24 from the UK, Brazil, Nigeria and Nepal. The aim of the project is to identify global and context-specific risk factors for depression in adolescence, involving high- and low-middle-income countries around the world. Such risk factors (ranging from biological, to cultural and social ones) could then be integrated into health care services across the world, and could help to early identifying and treating depression in young people.

For the general public, several online learning courses are now available to help parents and teachers to identify signs of depression in adolescence.

These are just some of the initiatives that are ongoing to promote early intervention in adolescent depression. There is still a lot of work to do, but at least now it is the time that academics, clinicians, mental health professionals, teachers, parents and young people are all coming together: they are all working together to create preventative interventions.

So that next time someone like Nicolas is depressed — in real life, not in a play — a parent or a teacher can realise what is going on, and can approach him in the most considerate way, encouraging him to see a mental health professional who can offer him a treatment that is meaningful and engaging.

Let’s use what we see on stage to help us make real life better!


header image source: The londonist


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