The Differential Diagnosis of Adolescent Depression

The next question to ask is how long have the symptoms lasted? Usually, 1-2 days is considered a normal variation. If they have symptoms every day for 2 weeks or longer and feel like they cannot escape them, a real depression is more likely. They also might report they are regularly in a bad mood and have major trouble getting into a good mood or having fun.

Also ask about functioning each time you see an adolescent. How are you sleeping and eating? How are you doing in school? How are you getting along with your friends and family? Has there been a clear change in these areas paralleling the change in mood and energy?

If you think an adolescent has major depression, you have to immediately consider their safety. Depressed adolescents are at increased risk for substance use, drunk driving, and suicide, all major causes of mortality.

You have to screen every depressed teenager for suicidal ideation at this point. You do have to ask whether they have thought about harming themselves, whether they have any specific plan about how they will harm themselves, and at least ask about two of the most common means of self-harm (you should ask both the teenager and the parents).

Are they, their parents, or their grandparents taking medication that could be used for an overdose? If so, how is that medication stored? Next, are any guns accessible to the teenager? You should be concerned about access if adolescents have any kind of suicidal ideation. Can they get to something that can kill them while they feel depressed, have an urge to end their suffering, or act impulsively when their judgment is impaired?

If the suicidal risk is high enough, if you feel that you cannot "connect" with the teenager, or if the patient is both "hopeless and helpless," you have to act quickly, even that day. A small minority of patients will reveal an active wish and/or plan to kill themselves. An emergency psychiatric evaluation is indicated.

Often, there is a wish to help an adolescent quickly, and you might wonder if you should prescribe antidepressant treatment right in your office at this initial consult. However, I don’t advocate for pediatricians to start antidepressant treatment on their own unless they have a special interest, some training or experience, and can provide comprehensive follow-up. Adolescent depression is very complicated and often is best addressed with a combination of medication, life changes, and therapy. If at all possible, when you identify a depressed adolescent, get a comprehensive mental health evaluation that addresses any family problems, family history of psychiatric disorders, a more in-depth look at the child’s school performance as well as his or her personality. The pediatrician could have a role in monitoring the antidepressant component of a comprehensive treatment plan, but only pediatricians with some added expertise should really be taking on depression on their own.

Some variations of adolescent depression worth noting include dysthymia, a long-lasting, chronic, low-level depression. You might also see teenagers with comorbid anxiety and depression, and often one component is predominant at a time. In addition, you might encounter the small percentage of kids who are manic. Manic adolescents can be euphoric, talk with pressured speech, focus on grand plans or ideas, and/or write prolifically in a journal about their schemes with the focus on volume more than content.

Taking care of depressed teenagers in primary care, even in collaboration with a mental health professional, is rewarding as most improve, but stressful. The clinician worries about all the risk factors from drinking to suicide. If interested, read more and gradually take more responsibility for your depressed adolescents with the support of a mental health colleague.

Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. He has no relevant disclosures. E-mail him at pdnews@elsevier.com.

For more information, see guidelines from the American Academy of Pediatrics that address the identification, assessment, and initial management of adolescent depression in primary care (Pediatrics 2007;120:e1299-312).

For a list of DSM-IV criteria for major depressive episode, see Table I in the following publication (J. Fam. Med. 2009;58:187-92).