Pediatrics (System-Integrated)

Pediatric depression: screening and treatment

Clinical Overview and When to Suspect Pediatric Depression

— Key distinction: Irritability (not sadness) can substitute for depressed mood in pediatric patients — a frequent Step 3 trap. The "sullen, snappy" teen may meet criteria.

— Prevalence ~2% in children, jumping to ~8–13% in adolescents, with female predominance emerging at puberty (2:1).

— Suicide is the 2nd leading cause of death ages 10–24 in the US.

— Declining grades, school refusal, social withdrawal

— New somatic complaints (headache, abdominal pain, fatigue) without medical cause

— Sleep disturbance, appetite/weight change, substance use, self-injury

— Family history of mood disorder or suicide

— Screen all adolescents ages 12–18 for MDD (Grade B)

— Insufficient evidence for ages ≤11 (Grade I), but screen if clinical suspicion

— Screen ages 8–18 for anxiety (Grade B) — often comorbid

— PHQ-A or PHQ-9 modified for adolescents (most common in primary care)

— Score ≥10 suggests moderate depression warranting intervention

— Columbia Suicide Severity Rating Scale (C-SSRS) or ASQ for suicide risk

Definition: Major depressive disorder (MDD) in children/adolescents requires ≥2 weeks of depressed or irritable mood or anhedonia, plus ≥4 SIGECAPS symptoms, causing functional impairment.

Epidemiology:

When to suspect: Move beyond "moody teen" framing when you see:

USPSTF guidance (2022):

Preferred screening tools:

Risk factors: Family history, prior episode, chronic illness (diabetes, IBD, epilepsy), LGBTQ+ identity in unsupportive environment, trauma/ACEs, bullying, substance use, parental depression.

Board pearl: A PHQ-9 ≥10 in a 15-year-old at well-child check mandates a suicide risk assessment that same visit — do not defer. Document safety planning and means restriction counseling before the patient leaves.

Presentation Patterns and Key History

— Sleep: Insomnia or hypersomnia (teens often oversleep on weekends, can't wake for school)

— Interest: Loss of pleasure in sports, gaming, friends — anhedonia is highly specific

— Guilt/worthlessness: "I'm a burden," excessive self-criticism

— Energy: Fatigue, "always tired" despite adequate sleep opportunity

— Concentration: Falling grades, teachers report inattention (mimics ADHD)

— Appetite: Failure to gain expected weight in younger children; weight change ±5% in teens

— Psychomotor: Agitation (often irritability) or retardation

— Suicidality: Passive ideation → active ideation → plan → intent → preparatory acts

— Preschool/young children: Somatic complaints, separation anxiety, regression, "no fun" play, irritability

— School-age: Academic decline, social withdrawal, low self-esteem, somatic symptoms

— Adolescents: Resemble adult MDD but with more irritability, hypersomnia, hyperphagia, mood reactivity

— Home, Education, Eating, Activities, Drugs, Sexuality, Suicide/self-harm, Safety

— Always interview adolescent alone for portion of visit — confidentiality essential

— Active suicidal ideation with plan/intent

— Access to lethal means (firearms in home — ask explicitly)

— Recent self-harm escalation

— Psychosis, command hallucinations

— Severe functional collapse (not eating, not leaving bed)

Core symptom clusters (SIGECAPS adapted for pediatrics):

Developmental presentation differences:

Key history to obtain (HEEADSSS framework):

Red flags requiring same-day action:

Key distinction: Bipolar depression must be ruled out before starting an SSRI — ask about prior episodes of decreased need for sleep + elevated/expansive mood + grandiosity lasting ≥4 days (hypomania) or ≥7 days (mania). Starting an SSRI in undiagnosed bipolar risks antidepressant-induced mania.

Step 3 management: Always ask "Have you ever had a period where you felt the opposite — like you didn't need sleep and had tons of energy?" before prescribing.

Physical Exam Findings and Mental Status Assessment

— Poor grooming/hygiene, weight loss or gain, flat affect

— Cutting marks: forearms, thighs, abdomen — look for parallel linear scars in various stages of healing

— Burn marks, bruising patterns suggesting self-harm or abuse

— Bradycardia + hypotension + low BMI → screen for anorexia nervosa as comorbid/differential

— Tachycardia, hypertension → consider stimulant misuse, substance use

— Track marks (IV drug use), nicotine staining, lanugo (eating disorder)

— Knuckle calluses (Russell sign — bulimia)

— Tattoos with concerning content, recent piercings can signal distress

— Appearance/behavior: Eye contact, psychomotor activity

— Speech: Rate, volume (often soft, slow in depression)

— Mood/affect: Patient's stated mood vs. observed affect; constricted or flat affect common

— Thought process: Linear vs. tangential; rule out psychosis

— Thought content: Suicidal/homicidal ideation, hopelessness, hallucinations, delusions

— Cognition: Orientation, attention (poor concentration mimics learning disorder)

— Insight/judgment: Often impaired

— Ideation (frequency, intensity), plan (specificity, lethality), intent, access to means, prior attempts, protective factors (family, future orientation, religious beliefs)

General appearance:

Vital signs:

Skin and extremities:

Neurologic exam: Should be normal — focal findings prompt workup for organic cause.

Thyroid exam: Palpate for goiter; hypothyroidism mimics depression.

Mental status exam (MSE) essentials:

Suicide risk stratification components:

Board pearl: Any adolescent endorsing suicidal ideation with a plan and access to means (especially firearms) requires emergency psychiatric evaluation — do not send home. Document means-restriction counseling with caregivers.

CCS pearl: Order "suicide precautions" and "1:1 sitter" if admitting; physically remove access to belts, shoelaces, sharps.

Diagnostic Workup — Initial Labs and Medical Mimics

— TSH ± free T4: Hypothyroidism is the classic mimic — fatigue, weight gain, depressed mood, cold intolerance

— CBC: Anemia (especially iron-deficiency in menstruating adolescents) causes fatigue/low mood

— CMP: Liver/renal baseline before SSRI; electrolyte derangements

— Vitamin D, B12: Deficiencies associated with depressive symptoms

— Urine drug screen: Substance use is highly comorbid; cannabis, alcohol, stimulants common

— Urine pregnancy test: In any sexually active female before prescribing (paroxetine = category D)

— Mononucleosis testing: EBV often presents with fatigue and low mood in teens

— Baseline if considering TCAs (rarely first-line in peds, but used for comorbid enuresis/ADHD historically)

— Citalopram at higher doses (QTc prolongation — max 20 mg in adolescents <18 historically, though current evidence less stringent)

— Family history of sudden cardiac death or long QT

— PHQ-9 modified for teens: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–19 moderately severe, 20–27 severe

— Question 9 (suicidal thoughts) — any positive answer triggers immediate risk assessment

— GAD-7: Comorbid anxiety screen

— SCARED: Pediatric anxiety

— MFQ (Mood and Feelings Questionnaire): Alternative depression scale

Depression is a clinical diagnosis — no lab confirms it. Labs serve to exclude medical mimics and establish baseline before pharmacotherapy.

Recommended initial workup when clinically indicated:

When to order ECG:

Screening instruments (use, score, repeat):

Key distinction: A 16-year-old with fatigue, weight gain, constipation, and "feeling down" needs a TSH before an SSRI prescription — treating hypothyroidism may resolve symptoms entirely.

Step 3 management: Document a medical workup note justifying why labs were/weren't ordered; insurance and downstream clinicians rely on this.

Diagnostic Workup — Advanced Studies and Comorbidity Mapping

— Anxiety disorders: GAD-7, SCARED — present in ~30–75%

— ADHD: Vanderbilt scales — concentration symptoms overlap; treat depression first if both moderate, but if ADHD predates and is primary, stimulants may help

— Substance use: CRAFFT screen (Car, Relax, Alone, Forget, Family/Friends, Trouble)

— Eating disorders: SCOFF questionnaire

— PTSD: Trauma history, CATS or UCLA PTSD-RI

— Autism spectrum: May present as new "depression" when social demands escalate

— Persistent depressive disorder (dysthymia): ≥1 year (peds threshold, vs. 2 yr in adults) of depressed/irritable mood most days

— Disruptive mood dysregulation disorder (DMDD): Severe recurrent temper outbursts + persistently irritable mood between, onset before age 10, diagnosed ages 6–18 — not bipolar

— Adjustment disorder with depressed mood: Symptoms within 3 months of identifiable stressor, don't meet MDD criteria

— Bereavement: Now can co-occur with MDD per DSM-5

— Mild: Few symptoms beyond required, minor functional impact → psychotherapy alone

— Moderate: Clear impairment, PHQ-9 10–19 → therapy ± SSRI

— Severe: PHQ-9 ≥20, suicidality, psychosis, severe dysfunction → combination therapy, urgent psych

Imaging: Not routine. Obtain MRI brain only with focal neuro signs, new severe headache, first-episode psychosis, or atypical features (e.g., regression in young child).

Sleep study: Consider if hypersomnia dominant or suspicion of OSA contributing to mood (obesity, snoring, daytime sleepiness).

Standardized assessment for comorbidities (rule of high comorbidity — >40% of depressed teens have a second diagnosis):

Distinguishing MDD from other mood diagnoses:

Severity classification drives treatment:

Board pearl: A 14-year-old with explosive outbursts daily and chronic irritability since age 7 has DMDD, not bipolar — avoid misdiagnosis that leads to antipsychotic/mood stabilizer overuse.

Step 3 management: Coordinate care plan with school (504 plan accommodations) once diagnosis established.

Risk Stratification and First-Line Management Logic

— Mild depression:

— 6–8 weeks of active support and monitoring (regular check-ins, psychoeducation, sleep hygiene, exercise, family support)

— Reassess with PHQ-9 — if no improvement, escalate to therapy ± medication

— Moderate-to-severe depression:

— Evidence-based psychotherapy (CBT or IPT-A) and/or SSRI

— Combination (SSRI + CBT) is superior to either alone for moderate-severe MDD (TADS trial)

— Severe with suicidality/psychosis: Refer to child/adolescent psychiatry; consider inpatient

— CBT (cognitive behavioral therapy): Best evidence; identifies/challenges negative thought patterns

— IPT-A (interpersonal therapy for adolescents): Focuses on relationships, role transitions

— DBT: For self-harm, emotion dysregulation

— Family-based therapy: Especially useful when family conflict drives symptoms

— Moderate-severe symptoms

— Failed 6–8 weeks of therapy alone

— Patient preference and shared decision-making

— Inability to access therapy (medication may be more available)

— Rule out bipolar (mania/hypomania history)

— Screen for suicidality, document safety plan

— Discuss FDA black box warning for suicidality in patients <25

— Set follow-up cadence: weekly × 4 weeks, biweekly × 4 weeks, then monthly

— Therapeutic effect takes 4–6 weeks — counsel on expectations

— Sleep 8–10 hours, regular schedule, limit screens before bed

— Aerobic exercise ≥30 min most days — meaningful antidepressant effect

— Reduce substance use, address bullying, school accommodations

AAP/GLAD-PC guidelines stratify by severity:

Psychotherapy options (first-line for mild-moderate):

When to add SSRI:

Pre-prescribing checklist:

Lifestyle pillars (always):

Step 3 management: Document shared decision-making conversation with parent and adolescent, including risks/benefits of SSRI, monitoring plan, and emergency contacts (988 Suicide & Crisis Lifeline). This is high-yield for the CCS-style management voice.

Pharmacotherapy — First-Line SSRI Regimens

— Fluoxetine — approved ages ≥8 (most evidence, first-line)

— Escitalopram — approved ages ≥12

— These two are first-line; choose based on age, side-effect profile, family history of response

— Start 10 mg daily, increase to 20 mg after 1–2 weeks if tolerated

— Range 20–60 mg; titrate every 4 weeks based on response

— Long half-life (~4–6 days) — fewer discontinuation symptoms, useful when adherence is shaky

— Start 5 mg daily, increase to 10 mg after 1–2 weeks

— Range 10–20 mg

— GI: nausea, diarrhea (first 1–2 weeks, often self-resolves)

— Headache, insomnia or somnolence, sexual dysfunction (ask explicitly in older teens)

— Activation syndrome: restlessness, agitation, insomnia, impulsivity, irritability — more common in pediatrics; can mimic mania

— Weight changes, increased sweating

— Suicidality: FDA black box — small absolute increase in suicidal thoughts/behaviors (4% vs. 2% placebo), no completed suicides in pediatric RCTs. Benefits outweigh risks for moderate-severe MDD.

— Serotonin syndrome (rare; risk with combinations)

— Hyponatremia (rare in peds), bleeding risk

— Weekly × 4 weeks, then biweekly × 4 weeks, then monthly for first 12 weeks (FDA recommendation)

— PHQ-9 at each visit; ask directly about suicidality

— Partial response (≥4 weeks): increase dose

— No response after 6–8 weeks at adequate dose: switch to another SSRI

— Failed 2 SSRIs: refer to psychiatry; consider venlafaxine or augmentation (TORDIA trial supports SSRI switch + CBT)

FDA-approved pediatric antidepressants for MDD:

Fluoxetine dosing:

Escitalopram dosing:

Sertraline, citalopram, fluvoxamine: Used off-label for MDD; sertraline and fluvoxamine FDA-approved for pediatric OCD.

Common SSRI adverse effects:

Serious adverse effects:

Monitoring schedule:

Treatment response:

Board pearl: Fluoxetine + CBT combination gave the largest response (71%) in the TADS trial for adolescent MDD — memorize this. Avoid paroxetine in adolescents (highest suicidality signal, worst discontinuation syndrome).

Second-Line Pharmacology and Treatment-Resistant Depression

— Switch SSRI: Fluoxetine → escitalopram or sertraline (most common first switch)

— Venlafaxine (SNRI): Off-label; TORDIA trial showed efficacy similar to SSRI switch when combined with CBT; boxed concern for BP elevation and discontinuation syndrome

— Duloxetine: FDA-approved for pediatric GAD ages ≥7, used off-label for MDD

— Bupropion: Off-label; useful for atypical depression, comorbid ADHD, sexual side effects from SSRI; avoid in eating disorders (seizure risk) and seizure disorders

— Mirtazapine: Off-label; sedating, increases appetite — useful when insomnia and weight loss dominate

— Aripiprazole add-on for severe/psychotic features

— Lithium augmentation (rare in peds)

— Thyroid hormone augmentation (T3)

— ECT: Safe and effective in adolescents with severe, refractory MDD, psychotic depression, catatonia, or acute suicidality — rarely used but on the table

— Repetitive TMS: FDA-approved for adolescents ≥15 with treatment-resistant MDD (2024 expansion)

— Ketamine/esketamine: Investigational in pediatrics; not standard of care

— Cross-taper generally preferred for short-half-life agents (sertraline, escitalopram)

— Fluoxetine's long half-life allows direct switch with washout

— Avoid combining with MAOI — 14-day washout (5 weeks for fluoxetine)

— Continue antidepressant 6–12 months after remission for first episode

— Two or more episodes: consider longer maintenance (1–3 years)

— Taper slowly (over 4+ weeks) to avoid discontinuation syndrome — FINISH mnemonic: Flu-like, Insomnia, Nausea, Imbalance, Sensory disturbance, Hyperarousal

Definition of treatment-resistant pediatric depression: Failure of adequate trial (4–6 weeks at therapeutic dose) of ≥2 SSRIs.

Second-line options:

Augmentation strategies (specialist territory):

Treatments to consider in refractory cases:

Switching SSRIs — practical approach:

Discontinuation:

Step 3 management: Before declaring "treatment resistance," verify adequate dose, adequate duration, and adherence — pseudo-resistance is common. Also reconfirm diagnosis (missed bipolar, substance use, untreated thyroid).

Special Populations — Medical Comorbidities and Hepatic/Renal Considerations

— SSRIs metabolized primarily via CYP450 in liver

— Reduce dose by ~50% in significant hepatic impairment

— Sertraline and escitalopram generally safer in hepatic disease than fluoxetine (long half-life, active metabolite norfluoxetine accumulates)

— Avoid duloxetine in chronic liver disease/heavy alcohol use

— SSRIs minimally renally cleared — generally safe

— Avoid duloxetine if CrCl <30 mL/min

— Venlafaxine: reduce dose 25–50% in renal impairment

— Sertraline is preferred SSRI in cardiac disease (best safety data)

— High-dose citalopram → QTc prolongation; baseline ECG if QT risk factors

— Type 1 diabetes: 2–3× risk; depression worsens glycemic control; ADA recommends screening

— Epilepsy: Bidirectional relationship; bupropion lowers seizure threshold — avoid

— IBD: Steroids contribute; coordinate with GI

— Cancer: Survivorship depression common

— Chronic pain, migraine: Duloxetine useful (dual indication)

— Fluoxetine and paroxetine are potent CYP2D6 inhibitors — affect atomoxetine, risperidone, codeine activation, tamoxifen

— Fluvoxamine: potent CYP1A2 inhibitor — affects caffeine, theophylline, clozapine

— Triptans + SSRI: serotonin syndrome risk (low but counsel)

— NSAIDs + SSRI: increased GI bleed risk

— Linezolid, MAOIs: serotonin syndrome — contraindicated

— Paroxetine and mirtazapine cause weight gain

— Fluoxetine and bupropion more weight-neutral or weight-losing

Hepatic impairment:

Renal impairment:

Cardiac comorbidity:

Chronic medical illness: Depression is highly prevalent in:

Drug-drug interactions to flag:

Obesity/metabolic:

Board pearl: A 16-year-old with type 1 diabetes and PHQ-9 of 14 needs depression screening built into every diabetes visit — ADA standard of care. Treating depression often improves A1c.

Step 3 management: Reconcile medication list at every visit; SSRIs interact with OTC dextromethorphan, St. John's wort, and tramadol — ask explicitly.

Special Populations — Younger Children, Pregnancy in Adolescents, LGBTQ+ Youth

— Limited RCT evidence for SSRIs

— Psychotherapy first-line (parent-child interaction therapy, family CBT)

— If medication needed, fluoxetine is preferred (only FDA-approved ≥8)

— Always pursue thorough evaluation for trauma, abuse, attachment issues

— Routine pregnancy screening before SSRI in sexually active females

— Sertraline preferred in pregnancy and lactation (best safety profile)

— Avoid paroxetine — associated with cardiac malformations (Ebstein anomaly risk, category D)

— Untreated depression in pregnancy harms maternal-fetal outcomes — do not reflexively stop SSRIs

— Counsel on neonatal adaptation syndrome (jitteriness, feeding issues, transient) and small PPHN risk

— 2–4× higher rates of depression and suicide attempts vs. cisgender heterosexual peers

— Family rejection is the strongest modifiable risk factor

— Use chosen name/pronouns; ensure confidential care

— Connect to affirming resources (Trevor Project, local support)

— Gender dysphoria itself is not a mental illness, but coexisting depression deserves treatment

— High rates of trauma, attachment disorders, and polypharmacy concerns

— Avoid reflexive antipsychotic prescribing; trauma-focused CBT preferred

— Coordinate with caseworker, ensure continuity through placement changes

— DSM-5 allows MDD diagnosis even within first weeks of loss if criteria met

— Persistent complicated grief disorder may need targeted therapy

— Look for overtraining syndrome, eating disorders, concussion-related depression

— SSRIs are not banned in most sports

Children <8 years old:

Pregnant or postpartum adolescents:

LGBTQ+ youth:

Foster care and adopted youth:

Bereavement:

Athletes:

Key distinction: A 14-year-old whose depression worsened after coming out to unsupportive parents needs family-based intervention and connection to affirming peer support — meds alone won't fix the environmental driver.

Step 3 management: For any pregnant adolescent on an SSRI, coordinate with OB for shared decision-making; do not abruptly discontinue.

Complications and Adverse Outcomes

— Leading complication — 2nd most common cause of death in US ages 10–24

— Firearms involved in >50% of pediatric suicide deaths — means restriction counseling is life-saving

— Prior attempt is the single strongest predictor of future attempt

— Cutting, burning, scratching — often serves emotional regulation function

— Not always linked to suicidal intent, but increases future suicide attempt risk

— Assess function, frequency, severity; DBT is evidence-based treatment

— Academic decline, grade retention, school dropout

— Social isolation, loss of peer relationships

— Disrupted family relationships

— Bidirectional — depression drives substance use; substance use worsens depression

— Cannabis use particularly elevated; alcohol, nicotine, vaping common

— Untreated MDD increases risk of recurrent episodes, chronic depression, anxiety disorders, eating disorders

— ~20–40% of adolescent MDD evolves to bipolar disorder — watch for hypomanic switches

— Obesity from inactivity, disordered eating

— Sleep disturbance with downstream cognitive and metabolic effects

— Sexually transmitted infections, unintended pregnancy from impulsive behavior

— SSRI-induced activation/mania — discontinue and reassess for bipolar

— Serotonin syndrome with drug interactions

— Discontinuation syndrome from abrupt SSRI cessation (especially paroxetine, venlafaxine)

— Weight gain, sexual dysfunction affecting adherence

— ~40% recur within 2 years; ~70% within 5 years

— First-episode in adolescence predicts adult MDD

Suicide:

Self-harm (NSSI — nonsuicidal self-injury):

Functional impairment:

Substance use disorder:

Comorbid psychiatric progression:

Medical complications:

Iatrogenic complications:

Recurrence:

Board pearl: A 15-year-old on fluoxetine for 3 weeks who now has decreased sleep need, pressured speech, and grandiose plans likely has SSRI-induced mania — stop the SSRI, evaluate for bipolar disorder, refer to psychiatry. This is a classic Step 3 vignette.

Step 3 management: At every follow-up, screen for emergence of mania, suicidality, and substance use — these change the treatment plan immediately.

When to Escalate Care — Hospitalization, Consults, and Crisis Management

— Active suicidal ideation with plan and intent

— Recent suicide attempt or aborted attempt

— Severe self-harm requiring medical care

— Psychotic symptoms (hallucinations, paranoia, command auditory)

— Catatonia

— Acute safety threat to self or others

— Inability of caregivers to ensure safety at home

— High imminent suicide risk

— Failed outpatient stabilization

— Severe functional collapse (not eating, not getting out of bed, dehydration)

— Need for medication initiation with intensive monitoring

— Need for ECT

— Partial hospitalization program (PHP): 5–6 hrs/day, 5 days/week

— Intensive outpatient program (IOP): 3 hrs/day, 3–5 days/week

— Mobile crisis teams, crisis stabilization units

— Severe MDD at presentation

— Treatment-resistant depression (failed 2 SSRIs)

— Diagnostic uncertainty (bipolar? psychosis? autism?)

— Comorbid substance use, eating disorder, severe trauma

— Polypharmacy considerations

— 988 Suicide and Crisis Lifeline (call or text)

— Crisis Text Line: text HOME to 741741

— Local mobile crisis teams, ED

— Trevor Project (LGBTQ+ youth): 1-866-488-7386

— Warning signs the patient can recognize

— Internal coping strategies

— Social contacts and settings for distraction

— People to ask for help

— Professionals/agencies to contact in crisis

— Means restriction — lock up firearms, medications

Indications for emergency psychiatric evaluation / ED referral:

Indications for inpatient psychiatric hospitalization:

Step-down options between outpatient and inpatient:

When to involve child/adolescent psychiatry:

Crisis resources (Step 3 likes patient counseling specifics):

Safety planning components (Stanley-Brown model):

CCS pearl: When admitting a suicidal teen, your initial CCS orders should include: admit to psychiatry, 1:1 sitter, suicide precautions, remove sharps/cords/belts, NPO if ECT planned, social work consult, parent notification, urine drug screen, CBC/CMP/TSH, PHQ-9 on admission, and pediatric psychiatry consult.

Key Differentials — Other Psychiatric Disorders

— Look for prior hypomanic/manic episodes (DIGFAST: Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep decrease, Talkativeness)

— Family history of bipolar disorder

— Early age of MDD onset, atypical features, psychomotor retardation, postpartum onset, antidepressant-induced switch

— Treatment: mood stabilizer (lithium, lamotrigine) ± atypical antipsychotic — NOT SSRI monotherapy

— ≥1 year (peds) of chronic low-grade depressed/irritable mood most days

— May have "double depression" with superimposed MDD episodes

— Children/adolescents with chronic irritability and severe temper outbursts ≥3/week

— Designed to reduce pediatric bipolar overdiagnosis

— Treatment: psychotherapy ± stimulants if comorbid ADHD; SSRIs may help

— Worry, restlessness, somatic symptoms

— Highly comorbid with depression (~50%)

— SSRIs treat both

— Identifiable stressor (parental divorce, school change, breakup)

— Symptoms within 3 months, don't meet full MDD criteria

— Treatment: supportive therapy; resolves with stressor or adaptation

— Trauma history, intrusive symptoms, avoidance, hyperarousal, negative cognitions

— Often misdiagnosed as MDD or ADHD

— Treatment: trauma-focused CBT, EMDR; SSRIs adjunct

— Anorexia nervosa often presents with depressive symptoms from malnutrition

— Treat underlying eating disorder; depression often improves with refeeding

— Cannabis, alcohol, stimulants, withdrawal states

— Symptoms resolve with sustained abstinence

Bipolar disorder (depressive phase):

Persistent depressive disorder (dysthymia):

Disruptive mood dysregulation disorder (DMDD):

Generalized anxiety disorder (GAD):

Adjustment disorder with depressed mood:

PTSD:

Eating disorders:

Substance-induced mood disorder:

Key distinction: A 13-year-old with chronic irritability since age 6 and ≥3 severe outbursts/week is DMDD, not bipolar — avoid mood stabilizers as first-line. Reserve "bipolar" diagnosis for discrete manic/hypomanic episodes.

Key Differentials — Medical and Other Causes

— Hypothyroidism — fatigue, weight gain, cold intolerance, constipation, depressed mood; check TSH

— Hyperthyroidism — can present with anxiety, irritability, weight loss

— Diabetes — uncontrolled hyperglycemia causes fatigue, mood change

— Cushing syndrome (iatrogenic from steroids common in peds with asthma, IBD)

— Addison disease — fatigue, weight loss, hyperpigmentation

— Iron deficiency anemia — common in menstruating teens, vegetarians; causes fatigue, low mood, cognitive symptoms

— Vitamin B12 deficiency — neurologic + mood symptoms

— Vitamin D deficiency — associated with depression

— Mononucleosis (EBV) — fatigue, low mood lasting weeks

— Post-acute COVID — neurocognitive and mood sequelae

— HIV — fatigue, mood symptoms; underdiagnosed in adolescents

— Lyme disease in endemic areas

— Post-concussive syndrome — sports-related; mood changes common

— Temporal lobe epilepsy — interictal depression

— Multiple sclerosis (rare in peds) — fatigue and depression

— Tumors (rare) — frontal lobe lesions can present as personality/mood change

— Obstructive sleep apnea — daytime fatigue, irritability, poor concentration

— Delayed sleep phase syndrome — common in teens, mimics depression

— Narcolepsy

— Isotretinoin (Accutane) — depression and suicidality warning

— Corticosteroids — mood swings, depression, psychosis

— Beta-blockers (propranolol for migraine) — fatigue, depression

— Hormonal contraceptives — variable mood effects

— Anti-epileptics — levetiracetam, topiramate, phenobarbital

— Alcohol, cannabis, opioids, stimulant withdrawal — all mimic depression

Endocrine:

Nutritional deficiencies:

Infectious:

Neurologic:

Sleep disorders:

Medication-induced:

Substance use:

Board pearl: A 16-year-old on isotretinoin for severe acne who develops new depressed mood needs isotretinoin reassessed — iPLEDGE program mandates mental health monitoring; coordinate with dermatology.

Secondary Prevention and Long-Term Plan

— First episode: Continue for 6–12 months after remission to prevent relapse

— Second episode: 1–3 years of maintenance

— Three or more episodes: Consider indefinite maintenance

— Slow taper over at least 4 weeks; longer for paroxetine/venlafaxine

— Plan taper during low-stress periods (avoid exam weeks, transitions)

— Monitor for discontinuation syndrome and recurrence

— Continued psychotherapy reduces relapse risk

— Sleep hygiene, exercise, healthy diet

— Social connectedness, structured activities

— Limit alcohol/substance use

— Stress management skills

— Identify personal warning signs (sleep changes, anhedonia returning, withdrawal)

— Action plan with specific steps (re-engage therapist, contact prescriber)

— Family awareness of warning signs

— Annual mental health check at primary care visits

— Primary care medical home maintains continuity

— Communication with school counselor (with consent), 504/IEP if needed

— Therapist updates with prescriber

— Family therapy if family dynamics contribute

— Don't let mental health visits replace routine preventive care

— HPV, meningococcal, flu, COVID boosters per schedule

— Adolescent well-visits annually with HEEADSSS screening

— Around age 18, plan handoff to adult primary care and adult mental health

— Discuss confidentiality changes, insurance changes (parental coverage to age 26)

— Provide written records, medication list, treatment history

Duration of antidepressant treatment:

Tapering strategy:

Maintenance therapy components:

Relapse prevention planning:

Coordination of care:

Vaccination and preventive care:

Transition to adult care:

Step 3 management: At discharge from inpatient psych, ensure follow-up appointment within 7 days (ideally 48–72 hours) — the post-discharge period is the highest-risk window for suicide. This is a quality measure and a board favorite.

Follow-Up, Monitoring Parameters, and Family/School Counseling

— Week 1, 2, 3, 4 (weekly × 1 month) — FDA-recommended monitoring for suicidality

— Then biweekly weeks 5–8

— Then monthly through month 3

— Then every 3 months during maintenance

— Any dose change resets to closer follow-up

— PHQ-9 score trend — aim for ≥50% reduction by 6 weeks, remission (<5) by 12 weeks

— Suicidality (always — even if doing well)

— Side effects, adherence, sleep, appetite, energy

— Substance use

— School functioning, social engagement

— Family stressors

— Emergence of mania/hypomania

— Verify patient is actually attending sessions

— Coordinate with therapist (with consent)

— If poor fit, help find new therapist

— Educate on illness model — depression is biologic, not character flaw or laziness

— Encourage parental warmth and structure, avoid criticism

— Address parental depression — treating parent improves child outcomes (STAR*D-Child)

— Coach on talking about suicide (asking doesn't increase risk — myth)

— Means restriction: firearms locked or removed, medications secured

— Written communication (with consent) about diagnosis and accommodations needed

— 504 Plan for accommodations (extended time, reduced workload, mental health breaks)

— IEP if educational impact is significant

— Bullying interventions

— Mood tracking apps, sleep journals

— Behavioral activation logs

Follow-up cadence after starting SSRI:

What to assess at each visit:

Therapy engagement:

Family counseling pearls:

School coordination:

Self-monitoring tools:

Board pearl: Improvement on PHQ-9 of <20% by week 4 at adequate dose predicts non-response — consider dose increase or switch rather than waiting another 4–6 weeks.

Step 3 management: Document patient/family education on the black box warning, expected onset of effect, and emergency contacts at every visit.

Ethical, Legal, and Patient Safety Considerations

— Most US states allow minors to consent to mental health treatment at varying ages (often 12–16)

— Establish confidentiality agreement at start: "What you tell me is private, EXCEPT if you're in danger of hurting yourself, hurting someone else, or being hurt by someone."

— Always carve out time alone with adolescent during visits

— Document the confidentiality discussion

— Suspected child abuse or neglect → mandatory report to CPS (state-specific) regardless of patient/family preference

— Sexual abuse, physical abuse, neglect, exposure to violence

— Report based on reasonable suspicion, not proof

— Failure to report = legal liability

— Credible threats against identifiable third parties → duty to warn potential victim and/or law enforcement (state-specific)

— Parental consent required for medications in most states

— Adolescent assent should always be obtained — discuss medication, expected benefits, side effects, black box warning

— Document both

— Must inform patient and parent of increased suicidality risk with antidepressants in patients <25

— Document risk/benefit discussion

— Provide warning signs to monitor

— Post-discharge from inpatient psychiatry is the highest-risk period — ensure 7-day follow-up, ideally 48–72 hours

— Bridge prescriptions for psychiatric meds at discharge

— Warm handoff to outpatient provider

— Means restriction reinforced before discharge

— Drug-interaction alerts (MAOIs, tramadol, triptans, linezolid)

— Avoid prescribing large quantities to actively suicidal patients (lethal means)

— Adolescent contraception counseling — many SSRIs and most antidepressants are safe with hormonal contraception

— Pregnancy decisions are confidential except where mandated otherwise

Confidentiality in adolescent care:

Mandatory reporting:

Tarasoff-style duty to warn:

Informed consent and assent:

FDA black box warning disclosure:

Transitions of care safety:

Pharmacist and EHR safety:

Reproductive health considerations:

Step 3 ethical pearl: A 16-year-old discloses suicidal ideation but asks you not to tell her parents. You must break confidentiality to ensure safety — this falls under the safety exception agreed upon at intake. Frame it transparently: "I told you at the start I'd need to involve your parents if you were in danger; let's plan how to share this together."

High-Yield Associations and Rapid-Fire Clinical Facts

USPSTF: Screen adolescents 12–18 for depression (Grade B); 8–18 for anxiety (Grade B); insufficient evidence ≤11 for depression (Grade I).

AAP/Bright Futures: Annual mental health screening starting at well-child visits.

First-line pediatric SSRIs: Fluoxetine (≥8 yrs) and escitalopram (≥12 yrs) — only FDA-approved for pediatric MDD.

TADS trial: Fluoxetine + CBT > fluoxetine alone > CBT alone > placebo for adolescent MDD. 71% combination response.

TORDIA trial: For SSRI non-responders, switching to another SSRI + CBT was effective; venlafaxine + CBT also worked but had more side effects.

FDA black box warning: SSRIs increase suicidal thoughts/behaviors (not completed suicides) in patients <25; absolute risk increase ~2%.

Paroxetine — avoid in pediatrics: Worst discontinuation syndrome, highest suicidality signal, pregnancy category D.

Bupropion contraindications: Eating disorders (seizure risk), seizure disorders, recent alcohol/benzo withdrawal.

Suicide statistics: 2nd leading cause of death in US ages 10–24. Firearms = >50% of pediatric suicide deaths.

PHQ-9 cutoffs: ≥10 moderate; ≥15 moderately severe; ≥20 severe. Question 9 = suicidality.

HEEADSSS interview: Home, Education, Eating, Activities, Drugs, Sexuality, Suicide, Safety — standard adolescent psychosocial assessment.

DMDD: New DSM-5 diagnosis to reduce pediatric bipolar overdiagnosis; chronic irritability + severe outbursts ≥3/week; onset before age 10.

Bipolar warning signs in MDD: Family history of bipolar, early onset, atypical features, psychotic features, antidepressant-induced mania.

High-risk medications causing mood changes: Isotretinoin, corticosteroids, levetiracetam, propranolol, hormonal contraceptives (variable).

LGBTQ+ youth: 2–4× higher suicide risk; family acceptance is the strongest protective factor.

988 Suicide and Crisis Lifeline: Call or text 988 (US, since 2022).

Post-discharge from psychiatric hospitalization: Highest-risk window for suicide — schedule follow-up within 7 days.

Board pearl: Memorize fluoxetine ≥8 and escitalopram ≥12 — the only two FDA-approved pediatric MDD SSRIs. Everything else is off-label.

Board Question Stem Patterns

Stem 1 — "Screening visit": A 14-year-old presents for annual well-child visit. PHQ-9 score is 13. She endorses passive suicidal thoughts but no plan. → Best next step: Complete suicide risk assessment, develop safety plan, initiate CBT and/or SSRI, schedule follow-up in 1 week, counsel on means restriction.

Stem 2 — "Antidepressant-induced mania": A 15-year-old started on fluoxetine 4 weeks ago for moderate MDD. Returns with decreased need for sleep, pressured speech, grandiose plans, and irritability. → Diagnosis: SSRI-induced mania, evaluate for bipolar disorder. Step: Discontinue SSRI, refer to psychiatry, consider mood stabilizer.

Stem 3 — "Medical mimic": 16-year-old with 6 months of fatigue, weight gain, depressed mood, constipation, cold intolerance. → First step: Check TSH before initiating SSRI. Hypothyroidism is the diagnosis.

Stem 4 — "Black box warning counseling": Parent asks about suicide risk of starting SSRI. → Response: Discuss FDA warning, absolute risk small, untreated depression carries higher risk; weekly monitoring × 4 weeks; emergency contacts provided.

Stem 5 — "Confidentiality": 16-year-old discloses suicidal ideation, asks you not to tell parents. → Action: Break confidentiality, involve parents, ensure safety; this falls under safety exception discussed at intake.

Stem 6 — "Drug selection in pregnancy": Pregnant 17-year-old with MDD. → Avoid paroxetine (category D); preferred SSRI is sertraline.

Stem 7 — "Treatment-resistant": 15-year-old failed adequate trial of fluoxetine, then sertraline. → Switch to different class (venlafaxine, bupropion) or augment with psychotherapy; refer to psychiatry; reconfirm diagnosis.

Stem 8 — "DMDD vs. bipolar": 9-year-old with chronic daily irritability and ≥3 outbursts/week since age 6. → DMDD, not bipolar. Treatment: psychotherapy ± stimulants if ADHD; avoid antipsychotics first-line.

Stem 9 — "Post-discharge": Adolescent discharged from psychiatric hospitalization after suicide attempt. → Follow-up within 7 days (ideally 48–72 hours); means restriction; bridge prescriptions; safety plan.

Stem 10 — "Combination therapy": Best treatment for moderate-severe adolescent MDD per TADS trial? → Fluoxetine + CBT.

Board pearl: When the stem mentions a new prescription of isotretinoin, hormonal contraceptive, corticosteroid, or beta-blocker preceding mood symptoms, think medication-induced depression before starting an SSRI.

One-Line Recap

Pediatric depression is a treatable, screenable condition (USPSTF Grade B ages 12–18) for which moderate-severe cases respond best to combination fluoxetine + CBT, while every clinical encounter demands suicide risk assessment, means restriction counseling, and structured follow-up.

Screen and stratify: Use PHQ-9 modified for adolescents at every well-visit ages 12–18; score ≥10 triggers suicide risk assessment and intervention; rule out medical mimics (TSH, CBC) and bipolar disorder before starting an SSRI.

Treat by severity: Mild → active monitoring + psychotherapy; moderate-severe → fluoxetine (≥8 yrs) or escitalopram (≥12 yrs) plus CBT (TADS trial: 71% response with combination); avoid paroxetine; counsel on FDA black box warning; expect therapeutic effect at 4–6 weeks.

Monitor relentlessly: Weekly × 4 weeks after starting/changing SSRI, then biweekly × 4, then monthly; reassess PHQ-9, suicidality, side effects, emerging mania, and substance use at every visit; continue for 6–12 months after remission for first episode.

Safety and systems: Document means restriction (especially firearms), 988 crisis line, school accommodations (504/IEP), confidentiality with safety carve-out, and 7-day post-discharge follow-up after psychiatric hospitalization — the highest-risk window for suicide.

Step 3 management: Coordinate primary care, therapist, school, and family; treat parental depression and family conflict in parallel; transition planning to adult mental health care begins by age 17.