← Diagnosis and Management Guides
Adolescent Depression
Key considerations: Active suicidality, Bipolar disorder presenting as depression, Substance abuse
Cannot miss
- Active suicidality
- Bipolar disorder presenting as depression
- Substance abuse
- Abuse/neglect
Likely diagnoses
- Major depressive disorder
- Adjustment disorder
- Persistent depressive disorder
- Anxiety disorder with depressive features
Red flags
- Suicidal ideation or self-harm
- Psychotic features
- Substance use
- Functional impairment (school refusal)
- Family history of bipolar or completed suicide
Workup
- history: PHQ-A, CRAFFT (substance use), Columbia suicide screen; Social history: school, friends, family, activities, drugs, safety; exam: Mental status exam, physical exam to rule out medical causes; labs: TSH, CBC, BMP (rule out medical causes); Urine drug screen if substance use suspected; imaging: Not typically needed; bedside: PHQ-A scoring, safety assessment
Management
- immediate: Safety assessment and plan; If actively suicidal: psychiatric emergency evaluation; general: Mild-moderate: CBT or IPT first-line; Moderate-severe: fluoxetine (FDA-approved for adolescent MDD) + psychotherapy; Monitor closely for suicidality in first weeks of SSRI (black box warning); Family therapy and school-based supports
Disposition
- admit: Active suicidal ideation with plan, psychotic features, unable to maintain safety; discharge: With safety plan, parent education, therapy referral, follow-up within 1 week; consults: Child/adolescent psychiatry
Clinical pearls
- Fluoxetine has the most evidence for adolescent MDD — start low (10mg) and monitor closely
- Combination therapy (SSRI + CBT) is superior to either alone — TADS trial
- Always screen for bipolar before starting an SSRI — antidepressant monotherapy can trigger mania
Source and review
- AAP/AACAP Adolescent Depression Guidelines 2018. Last reviewed: 2024-11-01