IN TEEN GIRLS, DEPRESSION AND RISKY BEHAVIOR MIGHT GO HAND-IN-HAND,
RESEARCH SUGGESTS

Somewhere within the messy American intersection of gender,
adolescence, sex, drugs and cultural messages, researchers have
located what they are carefully defining as an "association": Sexual
activity and experimentation with illicit substances may put a teenage
girl at significantly greater risk for depression than a teenage boy
who engages in the same behaviors.

This research also takes the widely held perception that teens who are
depressed engage in risky behaviors as acts of "self-medication," and
suggests that depression can also be the consequence, not just the
cause, of experimentation our culture regards as both morally deviant
and normal.

"Adolescents do the things adolescents do," says Martha Waller of the
Pacific Institute for Research and Evaluation at Chapel Hill, N.C.

Waller is the lead researcher of a study recently published in
"Archives of Women's Mental Health" and immediately distributed by
mental health agencies nationwide. Once a high school teacher, Waller
knows it's the rare adolescent who never tries a cigarette, drinks
alcohol, inhales marijuana or becomes sexually active to some degree.

These activities may be "developmentally appropriate" in our culture,
but at the same time, each carries risk.

"Abstainers," as she calls them, who avoid the risk by avoiding the
behavior, actually come to be regarded as "abnormal" as they reach
upper teens, where "they certainly become the minority."

Yet it appears that this generalized abstinence confers, at least
statistically, some inoculation against symptoms of depression.

"The longer you can hold them off, the longer they have for emotional
and physical development, the better," Waller says.

Looking at the study

The study's name is as ambitious as its topic: "Gender differences in
association between depressive symptoms and patterns of substance
abuse and risky sexual behavior among a nationally representative
sample of U.S. adolescents."

Funded by the National Institute for Drug Abuse, the study also used
data from the National Institute of Child Health and Human
Development. It is the "gender difference" aspect that struck the
researchers as most significant.

If teenagers are especially prone to depression (about one in four
report symptoms,) and women are more (about twice as) prone to
depression than men, it should not be surprising that teenage girls
suffer more symptoms of depression than teenage boys.

Sure enough, "At puberty, we see that the prevalence of depression
starts to really increase in girls but not boys, and this gender
difference has always been attributed to developmental changes in
girls such as hormonal changes," Waller says. "But in this study, we
find that for girls who have not experimented with smoking or drinking
or become sexually active, their risk for depression is no greater
than males, regardless of their developmental status."

In short, she says, "just being female does not necessarily put you at
greater risk for depression."

Other factors involved

However, being female and engaging in one or more risky behaviors -
the study looked at 16, ranging from infrequent cigarette smoking to
having sex for drugs or money - apparently can lead to depression,
more so than in male adolescents who behave the same ways.

Why would that be? It's possible there are gender differences that
make alcohol or nicotine or any drug react differently with brain
chemicals, Waller says, but "we really don't know what makes males
less vulnerable or females more vulnerable. As much progress as we've
made, there is still a 'boys will be boys' mentality. In sexual
activity, girls bear the greater burden. But even though there are
quantifiable societal differences, I'm guessing it's more complicated
than that."

Complicated it is: The study notes that the rate of depression among
adolescent females appears to increase with age; depression rates
decrease as adolescent males get older. American girls generally have
puberty before boys, throwing them into what Waller calls "an entirely
new social context, where older boys are paying attention to them at a
time when they're still relatively undeveloped."

Add to that the fact that brain structure and chemistry may be
affected by cortisol or oxytocin, hormones produced by experience,
such as romantic or sexual involvement, or stress, perhaps the stress
of risking personal harm or societal or parental disapproval.

What to do

The study has several specific recommendations, but waving the results
in front of a daughter to say, "Don't experiment with anything, ever,
or you'll become depressed" is not one.

Findings "could easily be misconstrued," Waller admits, "but that's
certainly not what we're trying to do." She believes parents navigate
a fine line between wanting to influence their teenagers yet believing
they have no influence.

"They either say, 'I can't tell them anything,' so they stop trying,
or they try to control everything. You can't control every aspect of
your teenager's life. But I believe parents get to say, 'This is what
I expect of you,' and do it early, before they start. Say, 'I would be
disappointed if you did these things.'

"Not that smoking is ever good for you, but it is legal; not that sex
should be avoided forever; drinking alcohol may be something you do at
some point. It's just that at this point in your life, I expect you to
abstain, and here's why.'"

The study reported:

Girls who only occasionally used alcohol, tobacco, or drugs are two
and a half times more likely to suffer depression than girls who abstained.

Girls who used marijuana regularly were almost nine times as likely to
have symptoms of depression than girls who abstained.

Girls who used IV drugs were nearly 18 times as likely to suffer
depression compared to girls who abstained.

Generally, the more "deviant" the behavior, the greater the risk of
depressive symptoms.

In short, the greatest amount of gender-related depression appeared to
follow low and moderate levels of risky behavior.

There was no significant difference in depression rates among
teenagers of both genders who abstained. Involvement in risky
behaviors at low or moderate levels brought about a greater chance of
depression among girls. With high levels of risky behavior, the gender
difference was, as with abstainers, not significant.

Consider other factors

Dr. David Skripka is a UW Health psychiatrist with nine years of
experience with adolescents and their emotional and behavioral issues.
He points out that the study correlates risky behavior and symptoms of
depression, but doesn't take the next step of determining whether it
correlates to clinically diagnosed major depression.

He also notes there are disorders and early life experiences, other
than risky behavior, that could predispose a growing child to engage
in such behaviors and also become depressed - the death of a parent,
for example, or imbalances in brain systems that manage pleasure and
reward.

Dr. Peter Lake, medical director of Rogers Memorial
Hospital-Oconomowoc and its Child and Adolescent Center, also raises
questions about the study.

"I'm a bit skeptical about the study. It's difficult to say what came
first," he says. "We do see more that girls with drug and alcohol
issues are more susceptible to depression and anxiety, but at the same
time, a lot look like that but when the dust settles," he says, the
staff discovers that depression preceded the drug and alcohol use.

Waller acknowledges the study's limitations, noting that research is
always a process of uncovering new areas for research. The next push,
she suggests, needs to be in treatment research.

"If we treat mental health, does the substance abuse stop?" she says.
"If we treat the substance abuse, does the depression go away? That's
where we really need to go now. Possibly, we need to treat both at the
same time."

That's exactly what happens at Rogers Memorial, in contrast to many of
the 12-step programs that focus on drug and alcohol use but don't
address depression beyond having a psychiatrist oversee
anti-depressant medications, Lake says.

Also, if an adolescent is treated only for the depression, other
issues - including but not limited to drug and alcohol use - can be
missed.

"There's clearly an issue of girls with substance abuse that get over
their heads in a hurry, then things happen that they wish didn't
happen," he says.

He is referring to situations he hears about, such as teens hanging
out in a friend's basement when pot, alcohol, OxyContin or some other
drug is available and the friends-with-benefits expectation kicks in
or perhaps a girl is sexually abused.

Lake also has encountered teenage girls who have completed a 12-step
program or one of the wilderness experience programs addressing
alcohol and drug use.

"They say their substance abuse is better, but boy are they
depressed," he says. "Then I find out they had three or four
encounters with guys," either when they were high or when they were
passed out and think "something happened."

Another issue often missed when depression only or substance abuse
only are treated is attention deficit hyperactivity disorder (ADHD),
Lake says.

"Girls and young women who have ADHD primary inattentive type
(non-hyperactive ADHD) have terrible self-esteem issues," he says,
explaining they may consider themselves dumb (even when they're good,
smart kids), feel bored, daydream and have trouble keeping focused and
organized.

"They migrate to becoming very depressed and the substance abuse crowd
is accepting - or use helps them deal with social pain."

Whether the correlations ever evolve into cause-and-effect evidence,
one Madison 15-year-old (who, like the others quoted, wanted to remain
unidentified), said the study's findings rang true: "Whenever I see
kids using drugs or beer or cigarettes, deep down, I know they're not
really happy."

Counseling helps teens cope with addiction

Slumped like rag dolls in a circle of mismatched sofas and chairs,
seven Dane County adolescents wait silently. The grown-up arrives.
They sit a little straighter.

"I'll start. I'm Shelly. Drug of choice, cocaine. I've been straight
for 22 years. I wanted to make a safe place for young people to go so
they could become functional with life and feelings without drugs."

Connections Counseling, which Shelly Dutch founded and has directed
for the past four years, offers group and individual counseling for
teenagers who are recovering from alcohol and drug use.

"I was in middle school," Dutch continued, "not depressed but
insecure. I felt like my dad liked my brothers better. I wasn't
popular. I was a little chunky. Drugs did something for me I could not
do for myself."

One by one, girls and boys ages 15 through 18 put their stories into
the circle. Drugs of choice: marijuana, cocaine, heroin, alcohol,
psychedelic mushrooms. Straight and sober 98 days. Three weeks. One
and a half days.

"My depression definitely came first," followed by cocaine and heroin,
an 18-year-old said. "I was diagnosed with depression when I was 10.
You can't cure depression until you cure the drug dependency."

Far from cured, having been through multiple detoxifications, he was
on his way to an out-of-state facility that specializes in
particularly difficult cases of dual diagnosis with a strong focus on
depression.

"I never felt depressed at all before I started using," said a
15-year-old. "And I wouldn't say I'm an unhappy person, now. But I
wouldn't say that using made me a happier person, that's for sure."

This particular group session included a 17-year-old girl's
graduation: To mark her three months of sobriety, there was pepperoni
pizza all around. Her mother and baby sister joined the
celebration.

"My wish for you," the mother struggled to communicate to her daughter
through tears, "is that you will really understand your worth, your
value as a person, all the great attributes you have, and not put
yourself into any situation where you might do anything
self-destructive."

Baby Sister sat nestled between the teenager and her mother, watching,
listening, learning. The ones who had been straight only a few days
watched and listened to the one who had made it to three months. On
the wall hung photographs of graduations for those who reached one
year.

The treatment plan is to instill enough hope to get through the day,
one day at a time, until days pile up into months, years, life.