Tag Archives: depression

Jane Mendle, professor of Human Development, urges people to speak out about their mental illness and encourage others to seek help.

Reprinted from Motto from the Editors of Time, August, 30, 2017.

Jane Mendle, associate professor of human development

by Jane Mendle

A very specific image of Princess Diana comes to mind as we recognize the 20th anniversary of her death. We remember her as the “people’s princess” — from her jewel-studded wedding to her petrified final minutes in a Parisian tunnel. She walked through fields of landminesembraced an AIDS patient, introduced us to the vicious tenacity of the tabloid press and embodied the most glorious aspects of 1980s fashion.

But what is often forgotten is that Diana was also a paradox: under the magnificently poised image she presented to the world, she struggled with bulimia, self-injury and lingering feelings of worthlessness.

Princess Diana

In the early 1990s, toward the end of her marriage, Diana gave a series of interviews to promising to share “her true story.” In 1992, Andrew Morton published Diana: Her True Story (based on secret recordings Diana had an intermediary make for the author), which revealed that the princess was living with the eating disorder. In an 1995 interview with BBC, she described bulimia as a “symptom of what was going on in my marriage.”

Diana’s candid self-disclosures in these interviews may be her most powerful and unrecognized legacy. Her honesty helped chip away at the stigma surrounding mental health and encouraged others to get help. It is not an exaggeration to say that thousands of people changed their lives because Diana talked about hers.

Today, nearly one in six adults in the U.K. and one in five adults in the U.S. live with a mental illness. Millions in the U.K. and the U.S. currently have an eating disorder, which is often accompanied by depression or an anxiety disorder. But only a relatively small percentage of people will actually seek treatment. One of the biggest barriers is not access to help, but rather fear, shame and embarrassment. While a number of celebrities, including Demi Lovato and Catherine Zeta-Jones, have spoken out about living with mental illness in recent years, such frank disclosures were far less typical when Diana first opened up about her life experiences.

Even more unexpected was the clarity, honesty and depth with which Diana described her bulimia.“That’s like a secret disease,” she told the BBC in that 1995 interview. “You inflict it upon yourself because your self-esteem is at a low ebb, and you don’t think you’re worthy or valuable. You fill your stomach up four or five times a day — some do it more — and it gives you a feeling of comfort.”

“It’s like having a pair of arms around you,” she added, “but it’s temporarily, temporary.”

She said that she often came home from her official engagements “feeling pretty empty” and that she felt immense pressure to keep her marriage together despite the couple’s well-documented problems. “I was crying out for help, but giving the wrong signals, and people were using my bulimia as a coat on a hanger: they decided that was the problem — Diana was unstable,” she said.

For people who don’t understand why someone would feel compelled to binge and purge, Diana’s shockingly vulnerable explanations provided a simple answer. Binging, she said, functioned as a release valve for pressures and problems that seemed otherwise insurmountable. The stigma surrounding mental health can often be exacerbated by a lack of knowledge, and Diana’s candid interview allowed others to empathize and understand what it’s like to live with bulimia.

Diana’s disclosure had even more value for people with first-hand experience with bulimia. During the second half of the 20th century, rates of bulimia in Western, industrialized nations rose dramatically. Yet many women viewed bulimia as a private and deeply humiliating experience that should be kept hidden.

Remarkably, in the years during which Diana spoke publicly about her bulimia, rates of womenseeking treatment for bulimia in Great Britain more than doubled. The press dubbed this phenomenon the “Diana effect.” Mental health practitioners credited this shift to greater public awareness and dialogue about bulimia, as well as women identifying with Diana. If a princess could be bulimic, so could they. If she could explain why she hurt herself, they could recognize that side of themselves too. If she could overcome her eating disorder, they could too.

Self-disclosures, particularly of people in positions of power or visibility, can change how other people approach their own psychological health. Researchers have found that knowing someone else with a mental illness can encourage others to get help. “It is notable that the Princess’s death in 1997 coincided with the beginning of the decline in bulimia incidence,” researchers wrote in a 2005 study published in the British Journal of Psychiatry on time trends in eating disorder incidences. “Identification with a public figure’s struggle with bulimia might have temporarily decreased the shame associated with the illness, and encouraged women to seek help for the first time.”

Unfortunately, after Diana’s death in 1997, those rates slowly returned to baseline. By 2000, the “Diana effect” had vanished. Currently, in the United States, we are in the throes of a new mental health crisis. A study published in Pediatrics last year found that between 2005 and 2014, there was a 37% increase in the number of individuals aged 12-20 reporting a major depressive episode. But there hasn’t been a corresponding rise in treatment rates.

Hopefully, the 20th anniversary of Diana’s death will reignite conversations about why it’s so important to speak openly about mental health and encourage others to seek help. Her sons have already taken up that task. Earlier this year, Prince Harry spoke frankly about seeking counseling to address his grief over his mother’s death. Meanwhile, Prince William appeared in a documentary about anorexia, where he discussed his mother’s experience with bulimia.

“We need to normalize the conversation about mental health,” Prince William said in the documentary. “We need to be matter-of-fact about it, and not hide it in the dark where it festers.”

Diana did not set out to be a mental health advocate. She simply told her truth and her narrative resonated. These days, we could use more truth-tellers like her.

Reprinted from the New York Times, June 6, 2016

by Perri Klass, M.D.girl alone 2

When girls come in for their physical exams, one of the questions I routinely ask is “Do you get
your period?” I try to ask before I expect the answer to be yes, so that if a girl doesn’t seem to know about the changes of puberty that lie ahead, I can encourage her to talk about them with her mother, and offer to help answer questions. And I often point out that even those who have not yet embarked on puberty themselves are likely to have classmates who are going through these changes, so, again, it’s important to let kids know that their questions are welcome, and will be answered accurately.

But like everybody else who deals with girls, I’m aware that this means bringing up the topic when girls are pretty young. Puberty is now coming earlier for many girls, with bodies changing in the third and fourth grade, and there is a complicated discussion about the reasons, from obesity and family stress to chemicals in the environment that may disrupt the normal effects of hormones. I’m not going to try to delineate that discussion here — though it’s an important one — because I want to concentrate on the effect, rather than the cause, of reaching puberty early.

A large study published in May in the journal Pediatrics looked at a group of 8,327 children born in Hong Kong in April and May of 1997, for whom a great deal of health data has been collected. The researchers had access to the children’s health records, showing how their doctors had documented their physical maturity, according to what are known as the Tanner stages, for the standardized pediatric index of sexual maturation.

Before children enter puberty, we call it Tanner I; for girls, Tanner II is the beginning of breast development, while for boys, it’s the enlargement of the scrotum and testes and the reddening and changing of the scrotum skin. Boys and girls then progress through the intermediate changes to stage V, full physical maturity.

In this study, the researchers looked at the relationship between the age at which children moved from Tanner I to Tanner II — that is, the age at which the physical beginnings of puberty were noticed — and the likelihood of depression in those children when they were 12 to 15 years old, as detected on a screening questionnaire.

“What we found was the girls who had earlier breast development had a higher risk of depressive symptoms, or more depressive symptoms,” said Dr. C. Mary Schooling, an epidemiologist who is a professor at the City University of New York School of Public Health, and was the senior author on the study. “We didn’t see the same thing for boys.” Earlier onset of breast development in girls was associated with a higher risk of depression in early adolescence even after controlling for many other factors, including socioeconomic status, weight or parents’ marital status.

Other studies, including in the United States, have shown this same pattern, with girls who begin developing earlier than their peers vulnerable to depression in adolescence. Some studies have found this in boys, though it’s not as clear. But there is concern that girls whose development starts earlier than their peers are at risk in a number of ways, and across different cultural backgrounds.

“Early puberty is a challenge and a stress, and it’s associated with more than depression,” said Dr. Jane Mendle, a clinical psychologist in the department of human development at Cornell University. She named anxiety, disordered eating and self-injury as some of the risks for girls. In her studies of puberty, she has found associations between early development and depression in both genders in New York children. In boys, the tempo of puberty was significant, as well as the timing; boys who moved more rapidly from one Tanner stage to the next were at higher risk and the increased depression risk seemed to be related to changes in their peer relationships.

Before puberty, Dr. Mendle said, depression occurs at roughly the same rate in both sexes, but by the midpoint of puberty, girls are two and a half times more likely to be depressed than boys.

Some of these children may already be at risk; Dr. Mendle said that early puberty is more common in children who have grown up in circumstances of adversity, in poverty, in the foster care system. But some of it is heredity and some of it is body type and some of it, probably, is chance.

Researchers have wondered about hormonal associations with depression; Dr. Schooling pointed out that their study found that depression was associated with early breast development, controlled by estrogens, but not with early pubic hair development, controlled by androgens. “There is no physical factor that we know about that would explain this; estrogen has been eliminated as a driver of depression in earlier research,” she said in an email. “We probably need to explore social factors to seek an explanation.” They also plan to follow up with their study population at age 17.

The biological transition of puberty, of course, occurs in a social and cultural context. One very important effect of developing early, Dr. Mendle said, is that it changes the way that people treat you, from your peers to the adults in your life to strangers. “When kids navigate puberty they start to look different,” she said. “It can be hard for them to maintain friendships with kids who haven’t developed, and we also know that early maturing girls are more likely to be harassed and victimized by other kids in their grade.”

Parents should be aware of the difficulties that children may experience if they start puberty earlier than their peers, but lots of children handle early development with resiliency, and even pride.

Children who start puberty early – say, 8 instead of 12 — are faced with handling those physical changes while they are more childlike in their knowledge and their cognitive development, and in their emotional understanding of what goes on around them.

Parents should keep in mind that the same protective factors that help children navigate other challenges of growing up are helpful here: All children do better when they have good relationships with their parents, and when they feel connected at school. And we should be talking about the changes to their bodies before they happen, and make it clear that all of these topics are open for discussion.