Teens do not usually announce they are depressed, even when asked general questions such as “how are you feeling?” To inquire about depressive symptoms (including suicidality), primary care professionals need to ask specifically about symptoms. Previous research demonstrates that inquiring about depression in a routine, systematic fashion, such as through the administration of a questionnaire, elicits more positive responses than asking those questions as part of a mnemonic-guided interview.2 This is in keeping with studies showing that for personal information, such as sexual activity and substance abuse, teens tend to be more honest on a computer-based questionnaire than when asked in a face-to-face interview. A recent study conducted in large pediatric practices found that the incorporation of depression screening increased patient and parent satisfaction with the practice.3 The study found that paper-based screens actually improved communication between the doctor and the patient, and the written responses helped the pediatrician focus the interview.

Although screening may be acceptable and feasible in primary care settings, little research supports the idea that screening on its own improves outcomes for adolescents with depression. Furthermore, there is still much debate about the comparative usefulness of universal screening (e.g., every teen presenting to a primary care setting would be screened) versus targeted screening of teens who are at high risk for depression.2 The latter approach has generally been endorsed because of (1) the lack of research evidence to support universal screening, and (2) the cost of universal screening when the yield may be low. Therefore, targeted screening of teens at high risk of depression may be more reasonable in primary care settings.

Risk factors for depression were highlighted in previous chapters (e.g., Chapter 2) and include (1) family history of depression, (2) past history of sexual or physical abuse, (3) history of trauma or family conflict, (4) history of previous depressive symptoms, suicide attempts, or (5) history of other common comorbid illnesses such as anxiety disorders, attention deficit hyperactivity disorder (ADHD), substance use, and chronic medical conditions.

The implementation of a depression screen in primary care settings can be challenging; Table 19.1 summarizes the steps involved. The first stage is to convince office staff that depression screening is an important component of routine clinical care. This may be best accomplished through office meetings with the other providers to discuss the benefits of depression screening. Another point of meeting with the office staff is to get their help in designing a screening protocol that will work smoothly and efficiently. The input and expertise of office personnel can help design the most efficient system. Although it is helpful to pilot-test a screening procedure, it is also important not to pilot anything until as many of the problems are worked out in advance as possible.

The staff will need to decide several issues. First, screening instruments should ideally be given to both parents and adolescents. However, this may not be feasible in primary care settings either because of staffing problems or because the teens may not present with their parents. In such situations, the adolescent alone should complete the screen. Ideally, primary care professionals should try to also obtain information from the family and other sources (e.g., teachers).

Second, the choice of the depression screen is critical. Unfortunately, not many well-tested screens for adolescents exist in the public domain. A depression screen should be chosen based on factors such as cost, length, ease of scoring, existence of translations into other languages, and acceptability to the adolescent and parent. In addition, instruments that ask specifically about suicide are very important with the adolescent population; not all screens include a suicide question. Perhaps the best validated screen in primary care settings is the Beck Depression Inventory (BDI).4 However, it is not free. Furthermore, for younger patients or those with reading problems, the BDI may be too difficult. The Mood and Feelings Questionnaire (MFQ)5 may be a better alternative: It is not copyrighted; it covers similar content to the BDI; unlike the BDI, it has a parent version; and it has been validated for children and adolescents. The Columbia Depression Screen (parent and child versions)3 and the Kutcher Adolescent Depression Scale (KADS)6 are free for use with permission (see Table 3.6). The KADS is included in Appendix 19.1.

Third, although screening at health maintenance visits fits in well with recommended guidelines, studies indicate that many cases are missed when psychosocial screening is not also done at the urgent-care visits. Depressed adolescents may not come for annual examinations but may present with headaches, stomachaches, or pelvic pain during urgent-care visits. Therefore, it may be necessary to conduct depression screens in teens during urgent-care visits.

Fourth, parents should be informed about what will be happening with their child at visits and told that practice screens do not interfere with the teen’s confidentiality. Depending on the practice, primary care professionals may want to (1) mail letters to the parents when patients reach the age of screening to inform them about the process, (2) give letters when they arrive in the waiting room, or (3) post information in the waiting room. The adolescent will usually be best informed on the day of the appointment. A cover sheet attached to the screen outlining similar information to that contained in the parent letter usually works well. It is important to explain if and how the information will be shared with the teen’s parent. It is also critical to encourage honesty.

Finally, which office staff member presents the screen to eligible adolescents also needs to be determined based on the structure of each practice. In some practices, the receptionist can hand out the screens and pertinent information sheets. However, this process will not work if the receptionist does not know which teens are eligible. The screens may also be administered by nurses or medical technicians who normally weigh the child or take vital signs. This allows a person more knowledgeable about the patient to hand out the screen. In addition, this may give the child the opportunity to complete the screen in the examination room, more private than the waiting room. In computerized offices, parents and adolescents may complete the screens either online before their visit, at kiosks in the waiting room, or on computer tablets. In addition to providing the screen, an office staff must also score the screen (unless a computer program does it). In most practices, this is generally done by the staff who handed out the screen. Many offices prefer primary care professionals to do the scoring because this enables him or her to become aware of which questions were positive and not merely glance at a total score. In fact, screens may be most useful to clinicians because they provide information that can focus their interview. The screen may be incorporated into the interview and thus give the primary care professional the opportunity to probe regarding positive answers and comment or affirm the negative responses. The best way to use screens is as a starting point to open up the topic and to follow up when the screens suggest that follow-up is needed. However, many clinicians feel uncomfortable with behavioral health issues and prefer to use the screens in a more algorithmic manner. In that case, cutoff scores must be chosen and are generally available for well-validated screens such as the MFQ, KADS, and the Columbia Depression Screen. That is, follow-up or referral will be needed when a certain score is reached.

Once the primary care professional recognizes a teen may be depressed either through the use of a screen or based on chief complaint, follow-up is a critical next step. It is important to remember that a positive screen does not always necessitate referral or treatment but does always require follow-up. It must also be kept in mind that a positive screen may be related to mental health issues other than depression. In addition, a person who does not have a diagnosis of depression may still be at risk for suicide.

Assessment and diagnostic procedures in the primary care setting vary greatly based on the comfort, knowledge and skills of clinicians. Some clinicians choose to refer all youth with any suspicion of depression or suicidality, others make the diagnosis but refer for treatment, and still others follow mild cases but refer severe or complicated ones. In addition, many geographic areas do not have access to child and adolescent mental health services, so primary care professionals need to manage patients despite their trepidation. A detailed description of assessment is presented in Chapter 3. To avoid repetition, we only discuss in this section issues particularly relevant to assessment in primary care settings.

A critical component of the evaluation of depression is conducting two separate interviews: one with the adolescent and one with the parent. Primary care professionals who treat younger children are accustomed to asking questions with the parent and child together. When treating adolescents, it is preferable to interview the adolescent privately; however, it is also important to have private interview time for the parent. Parents can provide information to guide the primary care professional or to confirm the diagnosis. Even if parents do not know that their teen is depressed, they may give details about their child’s functioning (“he is up all night” or “she quit the team”). It needs to be kept in mind also that parents may fear their teen’s wrath if they reveal “embarrassing” events. Finally, they may be uncomfortable discussing their personal or family history of depression or other mental health issues in front of their teen, information that could be relevant to a complete assessment.

Evaluation for major depressive disorder (MDD) covers all alternative diagnoses (for an algorithm for diagnosis, see Figure 1.1). Adolescents who do not meet the full criteria of MDD may still be quite impaired and in need of help (see Chapters 1 and 3 for criteria for MDD and subtypes). The key symptoms of depression that primary care professionals should inquire about are sadness/ irritability, loss of interest, increased guilt, low energy and concentration, appetite changes, psychomotor agitation/retardation, and suicidality (see also Figure 1.1). The primary care professional may also classify them as having mild, moderate, or severe depression. Table 3.3 can assist in defining the severity of a depressive episode. In general, patients with mild depression present with fewer depressive symptoms than those with moderate and severe depression and are less impaired in their functioning. Also, patients with comorbid illness, psychosis, or suicidality are considered to have moderate or severe depression regardless of the number of symptoms. A large proportion of patients in primary care settings present with mild depression.

Along with depressive symptoms, the primary care professional also needs to do a complete history, including past history of mental illness (e.g., previous depressions, treatments, trauma, and abuse history), past medical history, and family psychiatric history. Clinicians must remember that patients and families may not understand the information being elicited. Therefore, asking about “psychiatric history” should be avoided. Instead, the primary care professional should be specific about history of depressive symptoms, anxiety or worries, other emotional problems, drug or alcohol problems, suicide, and hospitalizations both in the patient and in the immediate and extended family. Because many mental illnesses are partially inherited, this information may help with the diagnosis. The family history may also be helpful for treatment planning. For example, if an adolescent’s mother responded poorly to antidepressants, the patient may be reluctant to start medication as first-line treatment. Finally, the primary care professional should inquire about comorbid conditions such
as attention deficit hyperactivity disorder and anxiety disorders. The presence of comorbid disorders may complicate the diagnosis and treatment. For example, an adolescent with depression and anxiety may be missing school because of low motivation from the depression and avoidance because of the anxiety disorder. Therefore, even if the depression improves with treatment, attendance may still be an issue if the anxiety disorder is not addressed.

Impairment must be present to make a diagnosis of a mental “disorder,” including depression. Therefore, one must assess a patient’s overall functioning in different areas including school (e.g., grades), home (e.g., conflict with family), and peers (e.g., spending time with friends). These questions may be helpful to evaluate functioning:

If clinicians are unable to perform a complete assessment, evaluation of the potentially depressed child must at least include a determination of risk of harm, either from self-inflicted injury or from impaired judgment. The primary care professional must therefore always assess for suicidal and homicidal ideation, self-injurious behavior, altered mental state, substance use, and access to firearms. Table 19.2 lists some tips to evaluate suicidality.

Finally, clinicians must assess for medical conditions that can mimic symptoms of depression, including mononucleosis and other viral conditions, malignancies, anemia, and hypothyroidism (see Table 1.4 for a more complete list). Many clinicians order thyroid function tests to rule out depression, but routine testing is not always considered necessary; rather, the standard of care dictates that clinicians assess for a thyroid disorder as part of their evaluation and choose laboratory tests as needed to help with that evaluation. A targeted physical examination, based on the history, is also important.

Whether primary care professionals decide to manage a depressed adolescent in their practice or refer for mental health support, patients and families alike expect some initial management. Sometimes this is done as a bridge before mental health services are available; other times, it may be the preference of the patient and family.

Initial management includes education for the patient and family about depression, including symptomatology and treatment options, and safety planning. Education is a critical part of initial management, especially given the stigma and lack of knowledge about mental illness in the general population. Many advocacy and professional groups have developed handouts for families that are
easily accessible either by mail or through the Internet; some of these are listed in the resources section at the end of the chapter. Appendix 19.4 list topics about depression that can be discussed with families and patients, Appendix 19.5 lists frequently asked questions about the treatment of depression.

Safety planning is also a critical aspect of the initial management of all cases. Primary care professionals should formalize a procedure for their practices to (1) make plans to ensure the safety of adolescents at risk for suicide, and (2) provide information to patients and families regarding safety in the home (see Appendix 19.4).