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August 16th, 2007

A Prescription for Parents

How do you know when your child at college needs help

 
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DEPRESSION

Depression is not just about feeling sad. It is an illness that also affects the ability to think and reason, and can cause insomnia, sexual dysfunction, and weight loss or gain. It is associated with other psychological problems including anxiety disorders, eating disorders, substance abuse, and suicide. It is a disease that affects every body system and many functions of the brain. And it is rampant on college campuses. Just because our kids say, “I’m fine” doesn’t mean they really are. We need to learn how to “listen” to the silence and be attentive to the signs of depression they may try to hide.

The Symptoms of Depression

Major depression shows itself in a combination of symptoms that interfere with normal life functioning. They may appear once, twice or many times over a lifetime. According to the Diagnostic and Statistical Manual of Mental Disorders, depression exists when five or more of the following symptoms (including one or both of the first two symptoms) are present over a two-week period:

  • Depressed mood most of the day.
  • Markedly diminished interest or pleasure in all or almost all activities.
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite.
  • Insomnia or increased sleeping.
  • Restlessness or slowing down of body movements.
  • Fatigue or loss of energy.
  • Feelings of worthlessness or excessive or inappropriate guilt.
  • Diminished ability to think or concentrate, or indecisiveness.
  • Recurrent thoughts of death (not just fear of dying), recurrent thoughts of suicide,
    or a suicide attempt.

Dysthymia and Bipolar Disorder

In addition to major depression, there are two other types of depression: dysthymia and bipolar disorder.

Dysthymia involves long-term chronic depressive symptoms that are less severe but still keep a person from being fully functional and enjoying life.

Bipolar Disorder (previously called manic-depressive psychosis) is a psychiatric illness in which a person has abnormal moods reflecting two opposite poles: depression on the one hand; and mania, a state of abnormally elevated energy, on the other. Students experiencing a manic episode may experience periods of poor judgment, impulsiveness, reckless behavior and sexual indiscretions. This is often followed by a period of depression and withdrawal. Bipolar disease is a complicatedproblem to treat because there are various forms, some of which are characterized by cycling moods with more frequent depressive periods, while another type can have frequent wide mood swings, with very psychotic, out of control behavior, occurring in rapid cycles.

We are probably seeing more bipolar illness on campus because of the popularity of antidepressants. It is fairly common to see a college student who comes in with depression and no evidence of manic behaviors (pressured, rapid speech, impulsive behaviors, euphoric mood, days of very little sleep, and grandiosity). So an antidepressant is appropriately started to treat the depressive symptoms. Unfortunately, antidepressants can trigger a first manic episode in someone who is bipolar. This is why it is so important to monitor students closely after starting an antidepressant, but many schools don’t have the resources to provide this level of care, which is unfortunate.

Bipolar illness has a strong genetic component, so if the illness runs in your family, your child should know this and report it to college physicians and mental health counselors in order to get proper treatment. Bipolar illness is very treatable, but requires a lot of time, resources, and sometimes a complicated, expensive regime of medication.

Symptoms Too Easy to Ignore


Most commonly, depression doesn’t show its face until a person is in his or her early- or mid-20s—just the time when he or she leaves home to attend college. When it hits, it’s not something students are familiar with. It’s not like the sore knee that they know acts up occasionally and when it does at college they know what it is and what to do about it. Depression seems to come out of the blue and its symptoms are such that whether the students are freshmen or seniors they and their families and friends don’t associate them with mental illness. We all have occasional sleep difficulties, changes in appetite, problems with concentration. But putting the constellation together and getting proper care makes the difference between an engaging, enjoyable college experience and a miserable one that often leads to leaves of absence or other ancillary problems.

Students tend to keep the symptoms of depression to themselves, but even if they do complain, they aren’t taken seriously. If they mention that they can’t sleep, they’re told by well-meaning family and friends, “That’s just because you’ve got a lot on your mind and the dorm is noisy and you’re in a strange bed.” If they say they don’t feel much like eating, they’re told, “Nobody likes cafeteria food.” If they mention that they don’t feel connected or like they belong, they’re told “Everybody has trouble making new friends in a strange environment.” And if they admit that they just don’t feel motivated they’re told, “You just haven’t found your area of interest yet,” or “Maybe you’re in the wrong school.” Soon, life experience becomes negative and hopeless. Negative expectations become self fulfilling prophecies: If you think no one likes you and you isolate yourself, then you do become socially isolated. These predictable, automatic reactions to the symptoms of depression keep the students from recognizing their problem and delay and delay treatment.

The stigma about depression is another factor that slows down the recognition and referral process. I get extremely frustrated hearing students and families saying that the student just needs to concentrate more, work a little harder, cut out social activities and things will fall into place. It’s the equivalent of telling a diabetic, they just need to workharder and their blood sugar will straighten itself out.

By the time they’re willing to step up and say, “No, these feelings I’m having are not normal and they’re not going away,” it is likely that the problem has already negatively affected their personal and/or academic lives in many ways.

Sleep Disorders

Sleep problems are probably the most common physical complaint of college students—and of the rest of the general U.S. population as well. In a paper entitled “Understanding Insomnia: Scope, Severity, and Solutions,” Gary Zammitt, Ph.D. who runs the sleep disorder clinic at St. Luke’s Roosevelt Hospital in New York, says that according to the most recent poll, almost 69 million Americans, or 35 percent of the adult population of the United States, experiences common symptoms of insomnia. At college, the numbers are even higher. A recent study found that only 11 percent of the students surveyed were getting a good night’s sleep. The rest of the sample had moderate-to-severe sleep complaints [Buboltz et al 2002].

Many students arrive at college knowing they have sleep problems, but many others develop “toxic” sleep patterns after they arrive. It is a rite of passage and badge of honor to stay up all night partying on the weekend or to stay up all night writing a paper or studying for an exam. For many students, it is part of the college culture and so telling our children to “get a good night’s sleep” will not solve the problem. But helping them understand the cumulative effects of these habits might sway them to re-think that lifestyle.

Confusing the Biological Clock

Students who habitually take to their beds in the wee morning hours will eventually reset their biological clocks—causing even further sleep problems. As the sun sets and the lights go low, normally the body reacts by releasing melatonin—a hormone that helps regulate the body’s cycles of sleepiness and wakefulness. When the sun rises and light reappears, the production of melatonin is suppressed. But when students stay in brightly lit rooms or sit in front of computer monitors late into the night, the release of melatonin is delayed causing circadian rhythm disorders. Case in point: Twice as many students as people in the general population report symptoms of delayed sleep syndrome [Brown, et al 2001] in which the circadian clock shifts so that falling asleep before 2 or 3 a.m. becomes extremely difficult. The syndrome is marked by difficulty falling asleep during the week, problems awakening at a planned time, and morning sleepiness that significantly impairs daily functioning.

Tips for Mental Health
Sleep is a general measure of how things are going. If your child complains of sleep problems such as difficulty falling asleep, early morning wakening, waking up during the night, or exceptional trouble getting out of bed in the morning, but then sleeps just fine when he or she returns home (or on weekends for commuting students), this may be an early signal of emotional upset. Sleep problems often become self-fulfilling prophecies for students. They get in bed and worry that they won’t be able to sleep, recognize they need sleep, and then stare at the clock, unable to relax and fall asleep. I’ll talk about ways to avoid this problem in a later section.

The High Cost of Sleep Deprivation

In his article, “Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep quality in university students,” Franklin Brown, Ph.D. reports that the consequences of sleep disorders are vast and variable and notes that the trend toward self-imposed sleep deprivation, irregular schedules, and poor sleep quality could have far-reaching implications for college students. “Poor sleep quality,” the article says, “can lead to significantly greater psychosocial distress. Examples include depression, anxiety, reduced physical health, general cognitive difficulties (such as poor problem solving and attention difficulties), and increased use of drugs and alcohol. Partial sleep deprivation (less than six hours of sleep per night) can lead to deficits in attention, concentration, memory, and critical thinking, along with increased depression, irritability and anxiety. Even students who regularly obtain eight hours of sleep per night, but shift their sleep schedule by more than two hours may experience attention, concentration, reasoning, and psychomotor difficulties, as well as increased irritability, anxiety, and depression.

Sleep problems during the college years are worth taking note of. In addition to the psychological effects, there are a variety of medical sleep problems such as sleep apnea, restless leg syndrome, narcolepsy, and delayed and advanced sleep phase syndrome that also interfere with daily functioning.

Whatever the cause of sleep disorders, they affect the quality of life for our children; they influence their academic performance, and they may be the first symptoms of other physical or emotional problems.

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The Author : Dr. Richard Kadison
Dr. Richard Kadison is the Chief of Mental Health Services at Harvard University
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