Evidence Based Strategies: Identifying and Treating Adolescent Depression

Column Author: Brianna Hafenstein, MD | Chief Resident 

Column Editor: Kathleen Berg, MD, FAAP | Medical Director, Office of Evidence-Based Practice, Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

From assessing development to providing anticipatory guidance, many tasks need to be completed during the adolescent well-child visit. However, one aspect that should always be emphasized is the screening and treatment of adolescent major depressive disorder (MDD).

The prevalence among adolescents of MDD in the past year increased from 8.1% to 15% between 2009 and 2019.¹ Unfortunately, data show that only 50% of adolescents with depression are diagnosed prior to adulthood.² Specifically, in primary care, 2 of 3 teenagers with depression are not identified by their primary care provider and, therefore, do not receive treatment.²

To improve these statistics, pediatricians should monitor for signs and symptoms of depression in adolescents such as sadness, school problems, sleep difficulties, irritability and mood reactivity. Screening tools can be helpful in identifying patients at risk. The American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force recommends annually screening children 12 years and older for MDD.^2,3 The Patient Health Questionnaire (PHQ) is a validated screening tool in the adult and adolescent populations.^2,4 Two versions exist – the full PHQ-9 and the PHQ-2 (the first two questions of the PHQ-9). If a patient screens positive on the PHQ-2, it is recommended they complete the PHQ-9. However, it is important to note that the PHQ-2 does not screen for suicidality and, when used alone, could potentially miss suicidal adolescents. The PHQ-9 assesses all diagnostic symptoms of MDD, including a question about suicidality. Additionally, it provides a score that can help providers identify severity.

To formally make a diagnosis, the DSM-V criteria is the gold standard⁵:

Once we identify teenagers with MDD, how do we care for them? Based on high-quality evidence, the AAP and the American Academy of Child and Adolescent Psychiatry recommend cognitive behavioral therapy (CBT) with initiation of a serotonin reuptake inhibitor (SSRI).^2,6,7 The two FDA-approved SSRIs in pediatrics are fluoxetine (age 8+) and escitalopram (age 12+). Other SSRIs can be considered if families are counseled on their off-label use. When prescribing any SSRI to teenagers, it is important to inform patients and caregivers of the FDA black box warning of increased risk of suicidality for those up to age 25.⁸ If suicidal ideations occur, patients should be titrated off the medication appropriately. If an SSRI is abruptly stopped, patients can experience dizziness, insomnia, gastrointestinal disturbances, sensations of electrical shock, confusion/poor memory, or mood changes. Therefore, SSRIs should be tapered before stopping.

When monitored for effectiveness, an SSRI should be taken for at least four to six weeks at a therapeutic dose to consider it an adequate trial. If improvement is insufficient after this period, the provider should switch to a second SSRI before switching drug classes and continue to encourage involvement in CBT.⁹ If improvement is still not achieved after the second SSRI trial, it is reasonable to consult with a psychiatrist. Once a patient experiences remission of symptoms, SSRIs should be continued for at least an additional six to nine months following a first-time episode of MDD.

As previously mentioned, when talking about adolescent depression, it is essential to address suicidality. Suicide is the second leading cause of death in ages 10-19 with 20% of high schoolers contemplating suicide yearly and 8% attempting yearly.³ In 2019, the prevalence of suicidal thoughts, plans, and attempts among adolescents with MDD were 9.8%, 5.3%, and 3.5%, respectively.¹⁰ When assessing for depression, it is important to screen for suicide and counsel families on the warning signs. If suicidality is identified, pediatricians should create a safety plan with family. This plan can include referring patients to inpatient psychiatric care, removing lethal means from homes, establishing close follow-up, and starting treatment for depression, if indicated.

While there is much to discuss during an adolescent’s well-child visit, screening for MDD should be a mainstay. Identifying and treating adolescent depression can dramatically improve, and even save, your patient’s life.

References: 

1. Daly M. Prevalence of depression among adolescents in the U.S. from 2009 to 2019: analysis of trends by sex, race/ethnicity, and income. J Adolesc Health. 2022;70(3):496-499. doi:10.1016/j.jadohealth.2021.08.026
2. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D; GLAD-PC STEERING GROUP. Guidelines for adolescent depression in primary care (GLAD-PC): part I. Practice preparation, identification, assessment, and initial management. Pediatrics. 2018;141(3):e20174081. doi:10.1542/peds.2017-4081
3. US Preventive Services Task Force, Mangione CM, Barry MJ, et al. Screening for depression and suicide risk in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2022;328(15):1534-1542. doi:10.1001/jama.2022.16946
4. Richardson LP, McCauley E, Grossman DC, et al. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics. 2010;126(6):1117-1123. doi:10.1542/peds.2010-0852
5. American Psychiatric Association. Depressive Disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
6. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292(7):807-820. doi:10.1001/jama.292.7.807
7. Walter HJ, Abright AR, Bukstein OG, et al. Clinical practice guideline for the assessment and treatment of children and adolescents with major and persistent depressive disorders. J Am Acad Child Adolesc Psychiatry. 2023;62(5):479-502. doi:10.1016/j.jaac.2022.10.001
8. Chapter 18 Depression and Bipolar Disorders. In: Marcdante KJ, Kliegman RM, Schuh AM, eds. Nelson Essentials of Pediatrics. 9th ed. Elsevier, Inc; 2023:66-71.
9. Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial [published correction appears in JAMA. 2019 Nov 5;322(17):1718]. JAMA. 2008;299(8):901-913. doi:10.1001/jama.299.8.901
10. Lu W, Keyes KM. Major depression with co-occurring suicidal thoughts, plans, and attempts: an increasing mental health crisis in US adolescents, 2011-2020. Psychiatry Res. 2023;327:115352. doi:10.1016/j.psychres.2023.115352