PsychEd4Peds: child mental health podcast for pediatric clinicians

29. Distinguishing depression from normal teen moodiness and demoralization with Dr. John Walkup

• Elise Fallucco • Season 2 • Episode 29

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How can you tell if a teenager is depression or if it is just normal moodiness, stress, grief, or even demoralization?  Dr. John Walkup joins us to talk about the cardinal features of depression... and how it LOOKS different than other forms of low mood.
We talk about:
1 - the distinct change in mood seen in teens with depression and how it is different from sadness

2 - how you can use a simple question, "Can you tell me about something fun you have done recently?",  to help you figure out whether a teen has clinical depression

3 - why kids with depression can *think* they have ADHD

Guest: Dr. John Walkup is an internationally-recognized child and adolescent psychiatry and the President Elect of the American Academy of Child and Adolescent Psychiatry.  He is Chair of the Pritzker Department of Psychiatry and Behavioral Health at Lurie Children's Hospital in Chicago. He is also the Margaret C. Osterman Board Designated Professor in Child and Adolescent Psychiatry. 

Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Dr. Elise Fallucco:

Welcome back to psyched for paeds, the child mental health podcast for pediatric clinicians, helping you help kids. I'm your host, Dr. Elise Falco, child psychiatrist and mom. What does teen depression look like? How can you tell the difference between depression and normal sadness, teenage moodiness, grief or even demoralization. To help answer these questions. We are honored and excited to have a repeat guest master clinician, Dr. John walkup.

And you may remember Dr. John walkup from some of his earlier episodes on fearless families. As well, as on treating anxiety with medication. But today he's coming back on the pod to talk to us about the Cardinal features that help us distinguish clinical depression in teens.

Dr. Elise Fallucco:

Dr. Walkup. In the times that we live in teens are exposed to a myriad of stressors and adverse life circumstances that negatively affect their mood. So when we have a teenager in our office with low mood in the context of multiple life stressors. We have to be considering that this could be normal. Demoralization rather than depression. Tell us about how you think about demoralization.

Dr. John Walkup:

For example, a kid who lives in adverse life circumstances could actually come to clinical attention at age 15 because they live in a tough neighborhood. they live with a single parent who's doesn't make a lot of money. They go to a school where the educational environment isn't great. And they got a 120 IQ and they've always wanted to be able to go to college, but they just realized their school's not prepping them for that. And they come to treatment pretty unhappy because they're just not dealing very well with this. They're a little bit more cranky and irritable. Demoralization, is a kind of a chronic sadness that doesn't go away. Very difficult to treat because it really requires an environmental change. And people can cope with it better or worse, but it's very difficult. If you can't change a person's life circumstances, they're going to be pretty unhappy.

Dr. Elise Fallucco:

So when you see this 15 year old kid in your office and you hear about what they're going through. You're saying we should be considering that this could be an appropriate reaction to stress that is distinct and different from depression. And you would call that demoralization. And we would treat demoralization with therapy. Definitely not meds. With the idea that therapy could help them cope with some of the stressors, chronic stressors in their lives. Or try to figure out what actions they could take to improve aspects of their situation. So demoralization definitely different than depression. What clinical pearls can you share with pediatricians about. How to differentiate depression from demoralization

Dr. John Walkup:

Yeah. So the first thing is there has to be a relatively distinct change in mood. And if you talk to teenagers and really listen to them, they'll say, I've been sad. It's not sad. This is different than that. And so my interview follows that. Have you ever had a terrible loss in your life? Yes. Is it like that or not like that? Oh, no, it's different than that. Okay. Can you describe it? Is it sad? And many kids will say, no, it's not sad. As a matter of fact, the only thing that really bothers me is I can't think anymore. I used to feel smart. Now I feel really dumb. My mind's just not working like it used to work. When people are clinically depressed, their minds don't work like it used to work.

Dr. Elise Fallucco:

So two key clinical features of depression are a distinct change in mood, different from sadness. And the second feature of clinical depression is cognitive slowing or problems. Thinking, feeling like your mind is not working the way it typically works.

Dr. Elise Fallucco (2):

As far as mood, you're asking the teenagers themselves, does this feel like the times when you get sad or when you've experienced loss, or does it feel different? And then the second question about your thoughts, have you noticed any change in your ability to think or your ability to concentrate? And I know from the kids I take care of, I had this straight A student actually, like you described. Who developed depression and without me asking her, she says, this is just really weird. I'm in school and it's I can't even pay attention. And she'd never had problems with this before. And it was around the time of where we thought that her episode began..

Dr. Elise Fallucco:

what else would you want to ask a teen to distinguish clinical depression?

Dr. John Walkup:

I say, tell me about something that you could do right now that would be a lot of fun. And and the kids who are demoralized will say, oh man, if I could just go someplace where, I didn't hear the gunshots at night and I could go to school and feel safe where I didn't have to get wanted by the cops when I came in man, that would be great for me. I'd really enjoy that kind of a school environment. The clinically depressed kids will say stuff like Don't ask me to think about anything that's fun, because right now, I know you're trying to make me feel better by asking me to think about stuff that will make me, I can't feel better, and as a matter of fact, now I'm disappointing you, and I feel guilty because I can't tell you that something would be fun for me, so please don't ask me those kinds of questions because I can't feel fun. Then tell me about something you did fun within the past couple of weeks that you really enjoyed. And if they go back and they say we went in a pizza with my friends how fun was that? Tell me about how fun it was to have pizza with your friends. They can't summon it. You don't get that brightness coming out. The other thing is and again, this is me, but I can walk a waiting room and identify the ones who are depressed. Because they carry it in their facial muscles. And there's a certain amount of anti gravity in your facial muscles when you have normal mood. So anybody who's seen you in person know that you have normal mood, because your facial muscles are right there, right?

Dr. Elise Fallucco:

Except for the forehead, which has been paralyzed by Botox.

Dr. John Walkup:

Edit that. I can see it in people's facial expressions. They lose some of the tone of those kind of normal mood muscles and they droop. And it's not skin saggy stuff. It's really got to do with the underlying musculature. And I can see it across the room. And I think it's got a quality to it. That's different than sad. People with sad can bounce. They still have those facial muscles working.

Dr. Elise Fallucco:

This is a great clinical Pearl about how to assess kids for anhedonia. You're saying, ask them to tell you about something fun that they did. And the kids with depression will have trouble coming up with the brightness and the. Kind of positive excitement when talking about. Fun things. Or as you put it, these kids don't have that bounce. Where they can step away from their sadness for a moment. And. Even experienced joy, thinking about something fun that they did. So to recap, we talked about. Kids with clinical depression. Experience a distinct mood. That's different than sadness and they have difficulty having fun and some slowed thinking. What other signs are you looking for to distinguish true depression in teens?

Dr. John Walkup:

For me, the sleep thing It's the waking up exhausted. I also spend a fair amount of time pursuing diurnal variation. Those kids who used to be morning kids and who are now evening kids, they've lost their energy in the morning. So I asked kids, I say, if you have a lot of work do you want to do that when you wake up first thing in the morning or late in the day? I used to be an early morning person, but I can't do that now. I, my best functioning is in the evening and even then it's not great. That's that diurnal pattern. That's kind of part of melancholia.

Dr. Elise Fallucco:

Now I'm thinking of our pediatric colleagues who are thinking like I don't have time in a 20 minute visit or a 10 minute visit to sift and sort, but you're giving them the key pieces and the pearls.

Dr. Elise Fallucco (2):

The things that you keep bringing up are mood,

Dr. Elise Fallucco:

diurnal variation where your mood is worse in the morning. You wake up feeling awful and you don't feel refreshed. You still feel exhausted.

Dr. Elise Fallucco (2):

the way you think, and the way you sleep.

Dr. John Walkup:

But depressed kids phase shift. So if your mood is best in the evening, what happens is you push the evening longer you have more energy in the evening, they do their homework they cope as best they can. But then they wake up exhausted because they don't have good quality of sleep. So there is some kind of something between kids who have fully phase shift. It's not just the fact that they have video games in their room all night long. There may be actually some mood contribution to that.

Dr. Elise Fallucco:

So mood worse in the morning They'd wake up feeling not refreshed, they have trouble thinking or concentrating or making decisions that's new, and that is time related to the other symptoms. And then if they're able to describe, more about their mood and they're have a higher EQ, what they could tell you is that this feels distinctly different than other times that they've experienced a loss or other times they've been sad. Is that about

Dr. John Walkup:

right? I think so. I think so. It's that it's the core symptoms of low mood plus inability to experience pleasure. That's the anhedonia piece and I hang my hat on that we do see some carb craving that comes with some of this. So some kids actually gain weight as opposed to lose weight. Depression has got to be pretty severe for people to lose weight. So there's other things that kind of come into the pattern but once you understand that you're looking for a pattern as a clinician, you're building your capacity to recognize the pattern you're open to the idea of pattern that you're sorting between normal human sadness, demoralization and this clinical entity, and once you get that, then all of a sudden the world will reveal itself to you and you'll be able to make these differentiations. The other thing is I think about it being seasonal for most of the kids I see, so it starts And in October around Halloween and goes to, April. So I think about seasonal patterns.

Dr. Elise Fallucco:

So we typically see worsening of mood and onset of depressive episodes around the late fall, early winter for our teenagers- october to April In the Northern hemisphere Before we wrap up, I just want to do a overview and recap of the things we talked about. When a pediatric clinician is trying to distinguish whether someone has true depression or whether it's some normal response to stress loss or chronic stressors, The Cardinal features and things that you want to look for are a distinct change in mood. That's different than regular sadness. And typically we'll see that diurnal variation where their mood and energy are worse in the morning than in the evening. And remember the clinical Pearl that you shared, where you asked the teenager, you say. Can you tell me about something fun that you've done and you see how they respond and you really look to see that bounce in their mood, in their facial expressions. And if you don't see that that's more concerning for depression. Also be important to ask kids, whether they noticed that they're having any problems thinking or making decisions or concentrating. And I know you and I have previously talked about how sometimes kids will misinterpret this as possible ADHD. And so when you have a teenager presenting to your office, complaining of problems, concentrating, always be thinking about depression. What would your take home message be for pediatricians? One take home thing that you want them to think about when they're evaluating kids for depression.

Dr. John Walkup:

Yeah I think what you're going to pick up on the PHQ nine is you're going to pick up any combination of normal human sadness, demoralization and clinical depression. And, once you have a high score there, it's up to you to begin to do the sort. What I love about pediatricians is many times they're treating kids that they know. And if they're all doing what I recommend them do, which is to get that family history at the first well baby visit, they know whether there's a family history of depression. So starting at age 13, 14 and 15, they're looking for that seasonal slump. They're looking for Complaints from the parents about sleep. They're looking for he's grumpy and irritable, and that's so different than what he used to be the sweetest kid in the world. And instead of saying, say, Oh my God, you got a positive family history. This is when this stuff starts happening. Let me spend a little bit more time digging a little deep. You can do what I just described in a 15 minute session. As long as you have that longitudinal relationship, you should know what's coming, and you should be knowing what to look for, and you should be knowing how to sift and sort. After listening to this about normal human sadness, demoralization and clinical depression, which are three different low mood states in kids.

Dr. Elise Fallucco:

Excellent. Thank you and very practical clinical pearls too, about how to sift and sort and how to do that in a short period of time to make sure that we're diagnosing the right thing This was so great. So awesome talking to you.

Dr. John Walkup:

Of course. Of course. I love doing this. We never talk about this stuff anywhere, really.

Dr. Elise Fallucco:

But this is the best stuff and this is the stuff people want to know and these are the questions I get asked a million times and sometimes I have good answers and I think you have a much better answer than I do. So this is great.

Dr. John Walkup:

I got a few more gray hairs than you do. So watch been watching it for a long time and fight in the fight, fight in the fight for kids. Because this whole idea of dimensionalizing unhappiness. Has really not served kids. Just not serve kids. My, my opinion.

Dr. Elise Fallucco:

To our listeners. Thanks for listening in tuning into psyched for paeds. We hope you'll join us next week as we continue the conversation with Dr. Walkup and talk specifically about treatment for depression using medication. And what do you do when somebody doesn't respond to their first trial of an SSRI? Check out our website, psyched the number four paeds, or follow us on Instagram and message us. If you have any questions, see you next week.