Adolescent Mental and Behavioral Health
What looks different in adolescents
Irritability and somatic complaints (headache, stomachache, fatigue) often replace classic sadness in adolescent depression; withdrawal and falling grades may be the only visible signs. Diagnose only when symptoms last two weeks or more, cause impairment, and represent a change from baseline - ordinary moodiness is brief, reactive, and does not cost function.
Screening and assessment
Use validated tools yearly: PHQ-2 followed by PHQ-A, GAD-7 for anxiety, SCOFF for eating disorders, CRAFFT for substances. Any positive suicide screen requires direct, non-euphemistic questioning, a collaborative safety plan, lethal-means restriction (firearms and medications), and risk-based disposition. Asking about suicide does not increase risk.
Treatment pearls and traps
Fluoxetine and escitalopram are first-line for adolescent depression and work best paired with CBT or interpersonal therapy. Before starting an SSRI, screen for bipolar disorder, because antidepressants can precipitate mania or rapid cycling. The boxed warning means close follow-up - weekly or biweekly early - and asking about suicidality at every contact; also watch for activation. Anorexia nervosa can present at a normal weight, and refeeding must be gradual to avoid refeeding syndrome; bulimia often appears at normal weight with dental erosion, knuckle calluses, and parotid swelling. Anxiety, OCD, and ADHD (symptoms before age 12 in two or more settings) are common comorbidities that change the plan.
Rule of thumb
When grades, sleep, and friendships all decline together, screen for depression, anxiety, substance use, and abuse before concluding the teen is "just being a teenager."