People thought Kat, 17, was being an "emo" teenager, but the truth was far more complicated.
Two years ago, she was diagnosed with depression.
She says: "As the symptoms of depression include being irritable and having mood swings, my family and friends thought I was being a 'moody' and emotional teenager and they told me to stop being 'difficult' or to snap out of it. Depressed people simply cannot snap out of depression."
Parents whose teenaged children suffer from depression sometimes mistake the illness for teen angst, says Mr Ang Poh Hee, head of Singapore Association for Mental Health YouthReach, which provides rehabilitation and support for youth aged between 12 and 21.
"The first reaction from family members is disbelief. They're usually in a state of denial. Parents can confuse depression with developmental issues of adolescence, mistaking it for angst and behavioural issues, such as laziness or teenage rebellion against authority," he explains.
"The earlier the acceptance of the illness, the greater the chance of the families seeking help, support and resources to help their child recover."
Depression is the most common mental illness in Singapore, according to the most recent large study done here on mental illness, the Singapore Mental Health Study.
Published in 2011 by a team of experts led by the Institute of Mental Health (IMH), the study projects that depression will affect 170,000 adults in their lifetime, or about 6.3 per cent of the adult population. But there are no available figures pertaining to teen depression.
The study indicates that fear of stigmatisation is a major factor in preventing people from seeking help for mental health issues. Indeed, like others interviewed, who are affected by depression, Kat declines to use her real name for fear of the stigma attached to mental illness.
"Depression caused me to lose out on my life back then. I was 15 and in the best class in my school. I lost my ability to concentrate in class and often skipped school," says Kat. "I was always tearful and living became a chore. I also started cutting myself and became addicted to it.
"My family wanted to help, but didn't know how to."
According to mental health professionals, there are many factors causing this illness.
Dr Karen Lim, a consultant at IMH's Department of Child & Adolescent Psychiatry, says these include biological (such as low serotonin levels in the brain), psychological (such as negative thought patterns) and social factors (such as parental divorce).
"Teenage depression can be triggered following a loss, such as the end of a romantic relationship, or death of a family member, friend or even a pet. It can be after a perceived disappointment with poor academic results. It can be related to gaming or Internet addiction.
It may surface after a physical or sexual assault or after a medical illness," she says, adding that the youngest sufferer of depression at IMH in recent years was eight years old.
In Kat's case, abuse was in fact one of the causes of her depression.
She recounts: "Eventually, under the advice of mental health professionals, we reported my father's abuse of my sister and me. That was one of the causes of my depression.
"Other causes include name-calling by tutors, as well as peers and seniors at school, resulting in a very low self-esteem and feelings of worthlessness. I was also under pressure to do well and concerned about not being able to keep up academically," she adds.
Her situation is common among those who suffer from the debilitating condition, which is characterised by profound feelings of sadness, worthlessness and hopelessness. Sometimes, this may be due to problems, or perceived problems in studies.
Ms Clare Schapiro is artistic consultant and director of Singapore Creations Etc., a theatre group that works with a diverse range of children, including at-risk youth.
In the course of working with at least 50 children since the group was founded in April, she has met two teens who have been hospitalised with depression and others who have expressed other mental health concerns.
"Fear of failure, especially academic failure, pressures about conforming to society and family relations are the top three concerns for the youth I've worked with," says Ms Schapiro.
The youth are encouraged and guided to create original productions based on their struggles. Next month, the theatre group will stage one such play, whose themes include teen depression.
Brenda (not her real name) knows the road ahead for her family and herself is a long one. The 17-year-old says that she found last year she could not cope with her examinations, and told her parents she had been dieting excessively and cutting herself. She also cited incidents of abuse she experienced, but declined to give details.
"My parents took some time to recognise that it was an illness. They scolded me for being selfish at first. It took them a month to take me to a psychiatrist, who diagnosed my eating disorder and depression," she says. "I have issues trusting my family. We're quite close, but we don't really talk about feelings on a deeper level."
She adds that after going for therapy together, her family is "more understanding. They're a lot more patient with me".
Brenda, who was anorexic and now is bulimic, says she takes medication to stabilise her moods and has been taught healthier coping mechanisms by mental health professionals. But she is "not very hopeful" about full recovery: "The anti- depressants and mood-stabilisers numb me so much that I can't cry and sometimes I want to cry, so I turn to cutting, restricting my food intake and purging - the release and high I get from it is unlike what any other coping mechanism can give me."
When depression strikes, Dr Lim says, "teens can begin to withdraw from loved ones, stop engaging in their favourite activities, be more irritable, moody, tearful or angry, have slipping school grades, neglect their basic self-care such as eating, engage in self-harm such as cutting themselves, and contemplate or even attempt suicide".
"Any of these can be taken as warning signs, with suicide being the top concern," says Dr Lim.
As a result of his depression, Khairul (not his real name), 18, has attempted suicide and been hospitalised twice. Since he tried to kill himself in February last year, he has dropped out of school.
His depression, he says, came about because of family and friendship problems, feeling alone and a skin problem - eczema - he has.
Brought up by his housewife mother - who also has depression - and his grandmother, Khairul remembers meeting his absentee dad only occasionally from the age of six. "I tried to make contact a few times, but my father didn't respond as much as before. I got busier when I got to secondary school. It felt like we drifted apart. I have not seen him now for about four years," he says.
"I felt like I couldn't relate to anybody most of the time, especially at school. I was quite a loner and even if I did manage to make friends, whenever I'm around them, I feel like I'm not being myself. I adapted to them, laughing at their jokes. When I go home, I look at myself and say, that's not you. Now I am myself and I am alone."
However, Khairul, an only child, is guardedly optimistic about his "painfully slow" recovery. In the past year, with the help of the Singapore Association for Mental Health, he has honed his interest in art, creating pointillist paintings and exhibiting his artworks at the library in Sengkang. Now a part-time worker at a supermarket, he is "pretty happy with his progress. I have been clean for a whole year: I have not attempted suicide".
Khairul's grandmother, Madam Fatimah, 57, is his main caregiver now; his mother remarried last year and moved out.
Madam Fatimah and Khairul have fewer quarrels now and she has learnt to accommodate his illness. She says: "I have to lower my expectations. I was sad when he dropped out of school. I wanted him to graduate, to go to university and maybe have a five-figure income next time. Not now. It's no point for me to force him."
venessal@sph.com.sg
How did you find out your child has depression and how do you cope with it? E-mail stlife@sph.com.sg
This article was first published on Nov 9, 2014.
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