Washington - When Mike Shooter was in medical school, he suffered the first of what he calls "thunderous depressions." More followed.
Shooter's efforts to come to grips with these experiences has made him acutely aware of what young people with mental-health problems endure and forged his career as a pre-eminent child psychiatrist in England.
Recently he published Growing Pains, which is based on 40 years of working with young people. The book explains why it's imperative to differentiate between depression and the ordinary but often intense difficulties some children face. He recently spoke with The Washington Post on these issues.
Q: Do you think young people are more vulnerable to mental illness now?
A: Research suggests that the United Kingdom is the least happy place for a child to be brought up in the Western world; America cannot be far behind. Some of this could be attributed to the grinding effect of poverty. But not all: The frenetic competition, in school, in the scramble for jobs, in peer-group relationships, means many children fall off the bottom of the ladder of competition and feel as if they've failed. Or are so unsure of their own worth that they sit up all night searching for "likes" on social media in lieu of proper friendships.
But it's not all bad news. There is currently much research into resilience: what enables some children to cope while others do not. I know from experience that there is one thing that can make all the difference: a relationship with an adult close enough to them, that supports them, listens to their distress and treats them as worthwhile. That person could be a relative, a family friend, a teacher or, dare I say it, a child psychiatrist.
Q: What's the difference between depression and sadness?
A: Depression is a formal psychiatric diagnosis with recognizable symptoms, well-researched treatments and a predictable outcome. Sadness is a normal reaction to sad circumstances, or a free-floating mood typical of adolescents.
The danger is that the sort of distress I describe, if it ever reaches the clinic, will either be squashed into a psychiatric category that it does not warrant or will be dismissed as a problem for which the psychiatrist has no answer. The children in "Growing Pains" have been unable to get help because they haven't met the formal criteria, reinforcing their sense of failure. These children need help, whatever we call them - sad or depressed.
Q: Is there a danger in labelling a disorder?
A: Labelling can be very dangerous. At best, it can fossilize a child's image and the way they are seen and handled by those around them. At worst, it can wreck their lives.
Q: How best, then, to support a vulnerable child?
A: Most helpful is a relationship that can hold the child in trust while we work together on trying to change things.
The trust must be earned. Some children feel safer talking in the privacy of a clinic. Some are so young and so frightened that they are beyond words and need special techniques to uncover the cause of their distress. Many will need to be seen on their own patch - at home, school, wherever they feel most comfortable. It may require negotiation with adults to secure the necessary space, and unless the child needs immediate rescue from harm, it will take time.
Q: Do we overmedicate?
A: I try not to blame people: the children and young people who have so often been blamed for their own distress and have felt so guilty that they have blamed themselves; parents and carers who are unable to understand what children are going through and are often just as needy of help; fellow professionals, who are desperate to help but are clinically trained and emotionally more comfortable with traditional ways of doing things.
So, yes, we are in danger of overdiagnosing distressed children and reaching too quickly for a prescription more appropriate for adult illness. But I understand why. Showing how a young person might fulfill - or not - a set of criteria and dishing out a course of pills is very obviously "doing" something, and the pressure to do something is huge.