A 15-Year-Old, a PHQ-A of 16, and a Mother on the Phone
A 15-year-old girl comes alone for a sports physical. When asked directly, she discloses 3 months of low mood, early waking, and grades that have fallen from A's to C's. She scores 16 on the PHQ-A, endorses passive suicidal ideation ('sometimes I think everyone would be better off') with no plan, no intent, no prior attempt, and says she would tell someone if things got worse. She uses cannabis two or three times weekly. Her parents are divorced and she alternates homes weekly. Her mother has bipolar I disorder and takes lithium. She asks that her mother not be told 'anything' about the visit. While you are finishing, her mother calls the front desk demanding to know what was discussed.
1. What can you tell her mother, and how do you frame the conversation with the adolescent?
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Start by telling the adolescent what you are going to do, before you do it. Confidentiality for a 15-year-old is conditional, and she needs to hear the conditions from you rather than discover them: if there is a risk to her safety, I will need to involve a parent or guardian, and I will tell you what I am going to say and to whom.
What the mother may be told: that she was seen, that there are concerns about mood and safety that require follow-up, that you recommend an evaluation and a safety plan, and that you need her help with medication storage and monitoring. What the mother should not receive is a verbatim account of the visit - the disclosure of cannabis use, the content of her answers about relationships, or the details of her thoughts - unless the adolescent agrees.
How to frame it with the girl: 'A score of 16 and thoughts that people would be better off without you means this is serious, and serious enough that I do not want you carrying it alone. I would like to help you tell your mother the parts that matter for keeping you safe. What would you like her to know, and what would you rather keep between us?' Most adolescents will agree if given a real choice about wording.
Document the risk assessment, the discussion, what was disclosed, and the rationale. Minor consent rules for mental health care vary by jurisdiction, but the safety-based limits on confidentiality are broadly consistent, and a parent who is brought in as an ally rather than as an informant is more useful to the plan.
2. What is your treatment plan, and how do you decide between psychotherapy alone and adding an SSRI?
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Severity drives the choice. A PHQ-A of 16 is moderately severe. For mild depression, psychotherapy alone is first line. For moderate to severe adolescent depression, the evidence favors fluoxetine plus cognitive behavioral therapy or interpersonal therapy over either alone.
Before starting an antidepressant, screen for bipolar disorder. Her mother has bipolar I. A family history alone is not a contraindication, but it raises the prior probability, so ask specifically about prior manic or hypomanic symptoms, decreased need for sleep with increased energy, grandiosity, and any past activation on a stimulant or antidepressant. If there is any suggestion of a bipolar spectrum illness, refer for psychiatric evaluation before starting an SSRI rather than starting one and watching.
If unipolar: fluoxetine 10 mg daily, titrated to 20 mg after 1–2 weeks if tolerated, with the option to go higher. Avoid paroxetine. Explain the boxed warning honestly: in the first weeks of treatment, suicidal thinking can increase, which is why follow-up is close - a telephone check within a few days and an in-person visit within 1 week of starting, then weekly for about 4 weeks, then every 2–4 weeks. Counsel about activation, nausea, headache, and the roughly 4–6 week lag before mood improves.
Cannabis: address it directly as a mood and sleep problem in its own right, and as something that will make the therapy less effective. It is not a reason to withhold treatment.
Arrange a therapy referral at the same time - the medication is not a substitute for it - and involve the school counselor with her consent.
3. What safety planning and follow-up do you put in place before she leaves the office today?
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A written safety plan, made with her, not for her:
- Her personal warning signs ('I stop answering texts, I sleep through dinner').
- Things she can do on her own - a specific playlist, walking the dog, a cold shower.
- People and places that distract her - a named friend, her aunt, the school library.
- People she can tell - two adults she names herself, with phone numbers written down.
- Professional and crisis contacts, including 988 and a local crisis line, written on the same page.
Lethal means restriction, which is the intervention with the strongest evidence base. Ask directly whether there are firearms in either home - she lives in two - and how they are stored; ask about medications, including her mother's lithium, and recommend a locked box. This is a concrete request to the parents, framed as a safety measure for the whole household rather than as an accusation.
Follow-up: telephone contact within 2–3 days, an in-person visit within 1 week, and a scheduled therapy intake. Confirm the crisis line is saved in her phone before she leaves.
Return thresholds, stated plainly: if she starts thinking about a method, if she cannot promise to stay safe, or if she uses substances to cope with the thoughts, she should go to an emergency department or call 988 rather than wait for the appointment. Document the plan, the means-restriction conversation, and the follow-up arrangements in the chart.