This article originally appeared on VICE Germany.
Timo Ewald was seven years old when he first realized that he was having less fun in life than the other kids in his class. While his classmates traded soccer cards on the playground and made social plans, Timo spent the majority of his school years—from preschool to graduation—alone.
"The other kids always looked happy," the 25-year-old remembers. "While, even at home, I had this feeling that I could never have fun." At the time, Timo didn't know where these thoughts were coming from. He had a nervous breakdown at 14 and was admitted to a psychiatric clinic for nine months—where, for the first time in his life, he was diagnosed with depression.
There isn't a definitive figure on how many children have depression. In Germany, the Psychotherapist's Council of North Rhine-Westphalia puts the figure at one in 20, while the German charity Depression Aide estimates that ten percent of teenagers suffer from depressive illnesses. Last year, a joint study by University College London and the University of Liverpool found that 24 percent of girls and nine percent of boys were depressed by the time they turned 14. And yet, despite the high numbers, very few receive adequate support.
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According to the World Health Organization (WHO), "depression is the predominant cause of illness and disability for both boys and girls aged 10 to 19, with suicide the third biggest cause of adolescents' deaths. Timo says that he too considered suicide: "If I hadn't received treatment, there's no way I would be here today."
To help others feel less alone, Timo has started a blog, through which young people can contact him if they want anything from help reading through a job application, to simply someone to hang out with. Until recently, Timo would have struggled to approach other people like this. He grew up a quiet child who hardly spoke. His instinct was always to retreat back to the comfort of his family.
Timo's mother consulted countless doctors in an attempt to understand why her child seemed to handle himself so differently compared to his peers. "My unwillingness to speak about my thoughts or feelings became a real burden for my parents," he says.
But amid the solitude, there would be unexpected moments when Timo's emotions would suddenly explode out of nowhere and into the open. "I was permanently irritable," he tells me. Two years before the nervous breakdown that saw him hospitalized for nine months, he had a particularly bad episode which involved being taken home by the police, and eventually to a psychiatric clinic.
"That was actually when I was first told that I might have depression," Timo explains. In the end, though, doctors diagnosed him with Asperger's Syndrome and told him he was obese. His weight, he explains, had ballooned as a result of years of being bullied. On top of this, the doctors found that Timo's reluctance to speak was caused by an anxiety disorder. "I suffered from mutism, so I found it difficult explaining to people what it was that made me feel depressed," he explains.
Child psychologist Stefan Lüttke believes the reason medical professionals find it difficult to determine whether an adolescent is living with a depressive illness is because research into depression has long focused almost solely on adults.
Even the WHO statistical system for defining depression, Lüttke tells me, "is not intended for children and teenagers, but for adults." Experienced child psychologists like Lüttke can still treat young patients who don't meet these criteria, but other medical professionals might struggle to detect the symptoms, especially for children under ten, who "have markedly different symptoms from adults."
According to Lüttke, the older a person gets, the more they demonstrate the outward signs of the illness. "Teenagers are often more irritable or aggressive," the psychologist explains, "while younger children retreat into themselves and try to avoid going to school."
Researchers like Lüttke are just beginning to establish and define a set of criteria for diagnosing depression in young people—but it's not easy, especially considering children often don't express themselves like adults expect them to, or simply don't express themselves at all.
"An important symptom to look out for are lasting, long-term behavioral changes," Lüttke says. "If someone gives up their favorite activities and routines for at least two weeks, you should take a closer look at what's causing it."
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The reasons for having a depressive illness are as varied as the behaviors of those they affect. Depression can be passed down genetically—if a parent is severely depressed, their children are four times as likely to suffer from a depressive illness.
In the BELLA long-term study for Psychiatric Health and the Quality of Life of Children and Young People, researchers found that external factors such as family and social environment strongly influence a person's mental health. Young people from disadvantaged backgrounds in particular suffered from stresses that could lead to depression, among other illnesses. At the same time, these children were also the least likely to receive treatment.
"My depression came from the way that my classmates treated me at school," says Timo. "Even in the later years, there were still some who found it entertaining to bully me." His parents had spent a considerable amount of time figuring out what was wrong with him, but even after his long stint in a psychiatric hospital at the age of 14 it took a while before he found the help he needed: "In 2008, I found a psychologist who helped me deal with my illness in everyday life," he says. "But it was only two years ago, really, that I started dealing with it myself." Timo learned that he needed to speak to others about his feelings—even if it didn't come naturally to him.
By 2020, the WHO estimates that depression and other mood disorders will be the second most common diseases worldwide. But even if the signs of depression are spotted early, it doesn't mean people will get the help they need.
A 2014 study by the Bertelsmann Charity found that half of those affected by depression are not treated adequately, and that 18 percent are not treated at all—a problem that can have far-reaching consequences later in life. "The majority of adolescents who have depression will go on to suffer from it as adults," Lüttke confirms.
The National Institute for Health and Care Excellence advises that people with depression should first be treated by a psychotherapist, before turning to medication. But young people are very rarely prescribed medication, Lüttke explains because there are not enough reliable studies on its efficacy.
Today, with the help of therapy, Timo has found ways of bringing order to his life. He's fully aware that this could be something he may struggle with for the rest of his life, but he tells me that he's learned to accept that his weaknesses are just as important as his strengths. "I try to see something positive in every situation," he says. "And now I'm feeling better than ever before."
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