SAN FRANCISCO – Teens may express feelings that indicate an increased risk for depression and give you an opportunity for early intervention and prevention if you know what to look for, suggest the findings of a qualitative study on teens’ sub-threshold symptoms of depression.

“Probing with sensitive questioning and understanding can help providers assess teens’ risks for depression,” said study coauthor Huma Khan, MD, of the University of Illinois Children’s Hospital in Chicago. “Furthermore, close follow-up with teens who mention certain topics, such as losing interest in activities or the loss of a loved one, also may help providers redirect the trajectory of depressive symptoms.”

Despite a lifetime prevalence of depression in adolescents of about 11% and a 12-month prevalence of 7.5%, about 8 in 10 teens do not receive adequate mental health treatment, explained Dr. Khan at the Pediatric Academic Societies meeting. Further, primary care providers often lack the time and training to recognize and follow up on early signs of depression in their teen patients.

To better understand ways in which teens may manifest sub-threshold depressive symptoms and possible coping mechanisms, Dr. Khan’s team conducted a qualitative analysis of 37 hour-long interviews with a subsample of teens enrolled in a larger study for adolescents at risk for depression. The teens, recruited from urban and suburban pediatric clinics, were aged 13-18 years and included 12 from Boston and 25 from Chicago. Ten were Hispanic, 15 were African American, and 12 were white.

The participants qualified for the study based on assessments using the Center for Epidemiological Studies Depression (CESD) scale and two questions about anhedonia and/or a depressed or irritable mood for at least 2 weeks. Teens with a current diagnosis of major depressive disorder or currently receiving therapy for depression were excluded.

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The adolescents underwent face-to-face interviews using the Kiddie–Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). These taped interviews then were transcribed for the content analysis.

Starting without a priori assumptions regarding potential findings, the researchers each independently used codes to identify key concepts in the transcripts and then categorized the codes. During regular meetings, they compared findings and continued until patterns in the content emerged.

The findings revealed that teens often express sadness in ways that don’t necessarily immediately call to mind a risk for depression.

“Our participants rarely described themselves as ‘depressed’ and instead used less specific terms such as ‘stressed’ or ‘down,’ ” Dr. Khan said. “Adolescents spoke of topics including unhappiness with school or family relationships that could be attributed to normal teenage angst by some. However, with further probing, adolescents revealed – in their own words – how profoundly impacted they were by their symptoms in various aspects of their lives.”

The research identified themes in three areas: external negative sources of stress, expressions of sadness, and coping practices. The three main sources of external stress identified included school pressure, family discord, and death of a close friend or family member.

The school pressures included difficulty understanding the material, completing work, passing classes, and achieving set goals. Problems with family ranged from tension and fighting to verbal and emotional abuse as well as stress from specific changes, such as divorce or frequent moves.

The researchers identified four main categories of sadness expression:

• Feeling stressed, sad, or down, often involving crying and interfering with their lives.

• Anger and irritability, often directed at others: One teen said, “Little things annoy me that used not to annoy me.”

• New feelings of apathy: One teen said, “I can still do the stuff I want to do, I just don’t feel like it. I used to love, love singing. Now, I sing, but I don’t really... it’s not all that.”

• Problems sleeping, including difficulty falling or staying asleep or sleeping too much.

“In contrast to the depression screening scales that only indicated sub-threshold depression, adolescents – with further questioning – spoke of significant symptoms of unhappiness, loss of interest in activities, and anger/irritability,” Dr. Khan said. “Some teens had little insight into their feelings.”

For example, statements made by the teens included, “They don’t understand why I’m upset. Sometimes I don’t either,” and “I just got really sad. I don’t know. You cry, but you don’t really know why you’re crying. You’re just crying.”

The adolescents told the researchers that spending time with friends was a major way of dealing with their feelings. In addition, two-thirds of the participants had a health issue that led them to visit their primary care provider or the emergency department. These conditions included asthma, allergies, thyroid issues, attention-deficit/hyperactivity disorder, migraines and headaches, arthritis, ulcers, abdominal pain, colonoscopy, fainting, acne, needing birth control pills, and panic attacks.

The researchers concluded that you need to tune into the feelings teens have through conversations about seemingly innocuous topics, whether it’s an annual check-up or an appointment for a specific concern. The statements and feelings expressed by the teens cut across ethnicities, indicating a possible “universality of symptoms for teens with predepression,” the researchers noted.

“The take-away message of our study is that adolescent providers can play an important role in the prevention of major depressive episodes by heavily relying on individual interviews with patients,” Dr. Khan said. “These conversations are powerful tools in uncovering psychological disturbances that may progress to debilitating depressive episodes if gone unnoticed.”

The research was funded by the National Institutes of Mental Health. Dr. Khan had no relevant financial disclosures.

Office visit conversations are clues to teens’ predepressive symptoms