A 15-Year-Old Who 'Gave Up' on Basketball: Depression, Cannabis, or Both?
Marcus, 15, is brought by his mother, who found him asleep at 4 p.m. on a school day and says he has "given up" on basketball. He reports 7 weeks of declining grades (two C's, one D), waking at 3 a.m. most nights, and eating at odd hours. PHQ-A 17, GAD-7 12. He denies suicidal ideation but says, "Sometimes I wonder why I bother." He discloses daily cannabis vaping since a knee injury ended his season in September and says it "turns my brain off." His mother asks whether he needs an antidepressant and wants to know everything he tells you. He asks you not to tell her about the vaping. No prior psychiatric history; his father has bipolar I disorder.
1. Before assigning a diagnosis, what would you clarify, and how does the differential change your management?
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Three explanations fit the same PHQ-A score, and I would not anchor on the first one.
- Cannabis-induced depressive disorder - daily use with anhedonia, sleep disruption, and amotivation, with symptoms beginning or worsening in the context of use.
- Major depressive disorder with secondary cannabis use for sleep and mood ("turns my brain off").
- Bipolar prodrome - a first-degree relative with bipolar I disorder plus a 15-year-old with fragmented sleep is a real signal, not a footnote.
What I would clarify: chronology (did low mood and anhedonia precede the vaping?), a structured hypomania screen (nights of decreased need for sleep with high energy, grandiosity, impulsive spending), the knee injury and any opioid or alcohol use, school and coach collateral, and body image or purging. Screening labs: TSH, CBC, ferritin.
Plan: negotiate a 4-week abstinence trial with motivational interviewing and a concrete quit plan, not a vague "cut down," plus behavioral activation and sleep hygiene, then repeat the PHQ-A. If the score stays high off cannabis, treat the depression. If he screens positive for hypomania, an SSRI alone is the wrong first move - refer for diagnostic clarification first.
Judgement point: a substance confounder justifies a short, monitored trial - not a reflexive prescription, and not a reflexive dismissal of his distress.
2. How do you assess and act on the suicidal statement, and what determines the level of care?
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Risk formulation, not a score. Passive ideation with no plan, no intent, no prior attempt, an engaged parent, and intact future orientation is low-to-moderate acute risk. But "wonder why I bother" in a 15-year-old with daily cannabis and a 17-point PHQ-A deserves a documented, structured assessment rather than reassurance.
- Ask directly: thoughts of self-harm, plan, access to firearms or medications, prior attempts, non-suicidal self-injury, and who he would tell.
- Use a validated tool (C-SSRS or ASQ) and record the answers verbatim.
- Interview him alone, then bring his mother in for safety planning with his permission.
Disposition: outpatient, with same-week therapy or psychiatric access, a written safety plan and crisis numbers, and means restriction - lock or remove firearms, limit available medications. Follow up in 1–2 weeks, not 6.
What would change my answer: a plan, access to lethal means, intoxication at the visit, or emerging intent → same-day emergency evaluation rather than a scheduled referral. His mother's request for medication is not a reason to hospitalize him; untreated access to an antidepressant at home is a reason to involve her in the safety plan.
3. His mother wants to know everything he says. What do you disclose about the vaping, and how do you handle the confidentiality conflict?
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Set the frame before the content. At the start, tell them both: what Marcus says is confidential, with three limits - imminent danger to himself or others, abuse or neglect, and specific state reporting duties. Substance use alone is not a mandated breach.
With the vaping disclosure: acknowledge that he told me something hard, then push toward supported disclosure - "I want to help you tell her in a way that doesn't blow up, with me in the room." His mother needs to know enough to supervise sleep, money, and safety; she does not need a verbatim transcript. If he refuses, I document the conversation and keep working with him. Breaching a 15-year-old's trust over cannabis to a parent who already suspects it usually buys nothing and costs the alliance.
What I would not do: promise blanket secrecy I cannot keep, or use disclosure to his mother as leverage or punishment.
What would change my answer: if the vaping were driving escalating risk - driving while high, overdose, selling - or if paraphernalia were accessible to younger siblings, I would become far more directive about parent involvement and say so plainly to Marcus first.