Somewhere within the messy American intersection of gender, adolescence, sex, drugs and cultural messages, researchers have located what they are carefully defining as an "association": Sexual activity and experimentation with illicit substances may put a teenage girl at significantly greater risk for depression than a teenage boy who engages in the same behaviors.

This research also takes the widely held perception that teens who are depressed engage in risky behaviors as acts of "self-medication," and suggests that depression can also be the consequence, not just the cause, of experimentation our culture regards as both morally deviant and normal.

"Adolescents do the things adolescents do," says Martha Waller of the Pacific Institute for Research and Evaluation at Chapel Hill, N.C.

Waller is the lead researcher of a study recently published in "Archives of Women's Mental Health" and immediately distributed by mental health agencies nationwide. Once a high school teacher, Waller knows it's the rare adolescent who never tries a cigarette, drinks alcohol, inhales marijuana or becomes sexually active to some degree.

These activities may be "developmentally appropriate" in our culture, but at the same time, each carries risk.

"Abstainers," as she calls them, who avoid the risk by avoiding the behavior, actually come to be regarded as "abnormal" as they reach upper teens, where "they certainly become the minority."

Yet it appears that this generalized abstinence confers, at least statistically, some inoculation against symptoms of depression.

"The longer you can hold them off, the longer they have for emotional and physical development, the better," Waller says.

Looking at the study

The study's name is as ambitious as its topic: "Gender differences in association between depressive symptoms and patterns of substance abuse and risky sexual behavior among a nationally representative sample of U.S. adolescents."

Funded by the National Institute for Drug Abuse, the study also used data from the National Institute of Child Health and Human Development. It is the "gender difference" aspect that struck the researchers as most significant.

If teenagers are especially prone to depression (about one in four report symptoms,) and women are more (about twice as) prone to depression than men, it should not be surprising that teenage girls suffer more symptoms of depression than teenage boys.

Sure enough, "At puberty, we see that the prevalence of depression starts to really increase in girls but not boys, and this gender difference has always been attributed to developmental changes in girls such as hormonal changes," Waller says. "But in this study, we find that for girls who have not experimented with smoking or drinking or become sexually active, their risk for depression is no greater than males, regardless of their developmental status."

In short, she says, "just being female does not necessarily put you at greater risk for depression."

Other factors involved

However, being female and engaging in one or more risky behaviors - the study looked at 16, ranging from infrequent cigarette smoking to having sex for drugs or money - apparently can lead to depression, more so than in male adolescents who behave the same ways.

Why would that be? It's possible there are gender differences that make alcohol or nicotine or any drug react differently with brain chemicals, Waller says, but "we really don't know what makes males less vulnerable or females more vulnerable. As much progress as we've made, there is still a 'boys will be boys' mentality. In sexual activity, girls bear the greater burden. But even though there are quantifiable societal differences, I'm guessing it's more complicated than that."

Complicated it is: The study notes that the rate of depression among adolescent females appears to increase with age; depression rates decrease as adolescent males get older. American girls generally have puberty before boys, throwing them into what Waller calls "an entirely new social context, where older boys are paying attention to them at a time when they're still relatively undeveloped."

Add to that the fact that brain structure and chemistry may be affected by cortisol or oxytocin, hormones produced by experience, such as romantic or sexual involvement, or stress, perhaps the stress of risking personal harm or societal or parental disapproval.

What to do

The study has several specific recommendations, but waving the results in front of a daughter to say, "Don't experiment with anything, ever, or you'll become depressed" is not one.

Findings "could easily be misconstrued," Waller admits, "but that's certainly not what we're trying to do." She believes parents navigate a fine line between wanting to influence their teenagers yet believing they have no influence.

"They either say, 'I can't tell them anything,' so they stop trying, or they try to control everything. You can't control every aspect of your teenager's life. But I believe parents get to say, 'This is what I expect of you,' and do it early, before they start. Say, 'I would be disappointed if you did these things.'

"Not that smoking is ever good for you, but it is legal; not that sex should be avoided forever; drinking alcohol may be something you do at some point. It's just that at this point in your life, I expect you to abstain, and here's why.'"

The study reported:

Girls who only occasionally used alcohol, tobacco, or drugs are two and a half times more likely to suffer depression than girls who abstained.

Girls who used marijuana regularly were almost nine times as likely to have symptoms of depression than girls who abstained.

Girls who used IV drugs were nearly 18 times as likely to suffer depression compared to girls who abstained.

Generally, the more "deviant" the behavior, the greater the risk of depressive symptoms.

In short, the greatest amount of gender-related depression appeared to follow low and moderate levels of risky behavior.

There was no significant difference in depression rates among teenagers of both genders who abstained. Involvement in risky behaviors at low or moderate levels brought about a greater chance of depression among girls. With high levels of risky behavior, the gender difference was, as with abstainers, not significant.

Consider other factors

Dr. David Skripka is a UW Health psychiatrist with nine years of experience with adolescents and their emotional and behavioral issues. He points out that the study correlates risky behavior and symptoms of depression, but doesn't take the next step of determining whether it correlates to clinically diagnosed major depression.

He also notes there are disorders and early life experiences, other than risky behavior, that could predispose a growing child to engage in such behaviors and also become depressed - the death of a parent, for example, or imbalances in brain systems that manage pleasure and reward.

Dr. Peter Lake, medical director of Rogers Memorial Hospital-Oconomowoc and its Child and Adolescent Center, also raises questions about the study.

"I'm a bit skeptical about the study. It's difficult to say what came first," he says. "We do see more that girls with drug and alcohol issues are more susceptible to depression and anxiety, but at the same time, a lot look like that but when the dust settles," he says, the staff discovers that depression preceded the drug and alcohol use.

Waller acknowledges the study's limitations, noting that research is always a process of uncovering new areas for research. The next push, she suggests, needs to be in treatment research.

"If we treat mental health, does the substance abuse stop?" she says. "If we treat the substance abuse, does the depression go away? That's where we really need to go now. Possibly, we need to treat both at the same time."

That's exactly what happens at Rogers Memorial, in contrast to many of the 12-step programs that focus on drug and alcohol use but don't address depression beyond having a psychiatrist oversee anti-depressant medications, Lake says.

Also, if an adolescent is treated only for the depression, other issues - including but not limited to drug and alcohol use - can be missed.

"There's clearly an issue of girls with substance abuse that get over their heads in a hurry, then things happen that they wish didn't happen," he says.

He is referring to situations he hears about, such as teens hanging out in a friend's basement when pot, alcohol, OxyContin or some other drug is available and the friends-with-benefits expectation kicks in or perhaps a girl is sexually abused.

Lake also has encountered teenage girls who have completed a 12-step program or one of the wilderness experience programs addressing alcohol and drug use.

"They say their substance abuse is better, but boy are they depressed," he says. "Then I find out they had three or four encounters with guys," either when they were high or when they were passed out and think "something happened."

Another issue often missed when depression only or substance abuse only are treated is attention deficit hyperactivity disorder (ADHD), Lake says.

"Girls and young women who have ADHD primary inattentive type (non-hyperactive ADHD) have terrible self-esteem issues," he says, explaining they may consider themselves dumb (even when they're good, smart kids), feel bored, daydream and have trouble keeping focused and organized.

"They migrate to becoming very depressed and the substance abuse crowd is accepting - or use helps them deal with social pain."

Whether the correlations ever evolve into cause-and-effect evidence, one Madison 15-year-old (who, like the others quoted, wanted to remain unidentified), said the study's findings rang true: "Whenever I see kids using drugs or beer or cigarettes, deep down, I know they're not really happy."

Counseling helps teens cope with addiction

Slumped like rag dolls in a circle of mismatched sofas and chairs, seven Dane County adolescents wait silently. The grown-up arrives. They sit a little straighter.

"I'll start. I'm Shelly. Drug of choice, cocaine. I've been straight for 22 years. I wanted to make a safe place for young people to go so they could become functional with life and feelings without drugs."

Connections Counseling, which Shelly Dutch founded and has directed for the past four years, offers group and individual counseling for teenagers who are recovering from alcohol and drug use.

"I was in middle school," Dutch continued, "not depressed but insecure. I felt like my dad liked my brothers better. I wasn't popular. I was a little chunky. Drugs did something for me I could not do for myself."

One by one, girls and boys ages 15 through 18 put their stories into the circle. Drugs of choice: marijuana, cocaine, heroin, alcohol, psychedelic mushrooms. Straight and sober 98 days. Three weeks. One and a half days.

"My depression definitely came first," followed by cocaine and heroin, an 18-year-old said. "I was diagnosed with depression when I was 10. You can't cure depression until you cure the drug dependency."

Far from cured, having been through multiple detoxifications, he was on his way to an out-of-state facility that specializes in particularly difficult cases of dual diagnosis with a strong focus on depression.

"I never felt depressed at all before I started using," said a 15-year-old. "And I wouldn't say I'm an unhappy person, now. But I wouldn't say that using made me a happier person, that's for sure."

This particular group session included a 17-year-old girl's graduation: To mark her three months of sobriety, there was pepperoni pizza all around. Her mother and baby sister joined the celebration.

"My wish for you," the mother struggled to communicate to her daughter through tears, "is that you will really understand your worth, your value as a person, all the great attributes you have, and not put yourself into any situation where you might do anything self-destructive."

Baby Sister sat nestled between the teenager and her mother, watching, listening, learning. The ones who had been straight only a few days watched and listened to the one who had made it to three months. On the wall hung photographs of graduations for those who reached one year.

The treatment plan is to instill enough hope to get through the day, one day at a time, until days pile up into months, years, life.

Resources

Adolescents and their families have many resources for dealing with both depression and risky behavior, including the following:

Connections Counseling, 100 River Place, Suite 4, 221-1500: An outpatient, comprehensive, holistic program offering assessment, individual and group therapy, family support, activities, and follow-up.

University of Wisconsin Adolescent Alcohol Drug Abuse Intervention Program, 122 E. Olin Ave., 262-1111: Does assessment of adolescents in high school, refers to treatment resources.

Mental Health Center of Dane County Inc., 625 W. Washington Ave., 280-2710, www.mhcdc.org: Mental health crisis phone, answered 24 hours daily, 280-2600. TDD/TDY, 280-2589. Mental health, alcohol and other drug assessment and treatment. Also coordinates its Teen Depression Project with middle and high schools, providing screening and support services for teens at risk for depression and suicide.

Rogers Memorial Hospital, Oconomowoc, 1-800-767-4411, www.rogershospital.org: Free phone assessments are available through this nonprofit accredited psychiatric hospital, which offers a range of mental health services and specializes in residential care for eating disorders, obsessive compulsive disorder and anxiety disorders, chemical dependency and child and adolescent mental health concerns.

Contact Nancy Webb through daybreak@madison.com.