Module 4: Promoting Mental Health in Adolescence

Depressed Teenage BoyDepression

More Than Feeling Sad

Depression is a relatively common mental health problem among teens. Onset at an early age is a risk factor for recurrence in adulthood, is associated with increased genetic vulnerability, and may be related to increased psychosocial stress. Teens who have been physically or sexually abused are also at high risk for depression.

Although females and males are equally affected in childhood, females are twice as likely as males to experience major depressive disorders. Hormonal factors may be involved, although psychosocial stress associated with female gender roles could also be implicated.

Depression in teens is not always characterized by sadness, but can be seen as irritability, anger, boredom, an inability to experience pleasure, or difficulty with family relationships, school, and work.

A recent Institute of Medicine report states that the first symptoms of depression and other mental health disorders typically occur two to four years before the onset of a full-blown disorder. Early detection of these symptoms creates a window of opportunity when preventive measures might make a difference—or possibly prevent specific disorders in at-risk groups.

Screening Teens for Depression

The US Preventive Services Task Force (USPSTF) now recommends screening all teens ages 12–18 for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up.

USPSTF has evaluated two tools for use in primary care settings:

  • Beck Depression Inventory for Primary Care (BDI-PC)
  • Patient Health Questionnaire for Adolescents (PHQ-A)

Because substance use and depression often occur together, consider screening with the CRAFFT screening tool.

Questions to Ask

For the Teen

  • Have you been feeling sad? Had difficulty sleeping? Frequently irritable?
  • Do you worry a lot or feel overly stressed out?
  • Do you find that you have lost interest in things you used to enjoy doing?
  • What do you do when you feel really down and depressed?

If the teen appears severely depressed or suicidal:

  • It sounds like you’ve been feeling pretty hopeless. Have you felt so bad that you wished you were dead or thought you would be better off if you were dead? (More questions on the next page, Suicidal Ideation And Behavior)

For Parents

  • Do you have any concerns about your teen’s emotional health?
  • Have you talked to her about your concerns?
  • Have you noticed any changes in her weight, sleep habits, or behaviors, such as becoming more isolated from her peers?
  • Is she frequently irritable?
  • (More questions on the next page, Suicidal Ideation And Behavior)

Provider Tips

  • Obtain a family mental health history, including depression, suicide, and substance use.
  • Screen teen for depression, if indicated. Share the results of the screening with the teen and parents. If screening identifies risk of suicide, see next page for further questions, tips, and guidance on Suicidal Ideation And Behavior.
  • Reassure the teen and parents that depression is not their fault, that it has a biological basis, and that it can be treated successfully.
  • Cognitive, behavioral, and other therapies; family intervention; and antidepressant medications can each be useful in the treatment of depression. Involve personnel from the teen’s school when appropriate.
  • Consider referral to a mental health professional PDF as indicated.
  • Learn about state laws on providing treatment for mental health concerns and substance use in minors with and without parental consent.
  • Using the guidance listed below, encourage teens and parents to get help if the teen shows signs of depression.

Guidance for Teens and Parents

For the Teen

  • Sadness and bad feelings are often temporary feelings that will pass, but sometimes your sad feelings don’t go away and last for weeks at a time. If you feel that you are too sad, hopeless, nervous, or angry to deal with your family, friends, school, or other activities, you may be depressed.
  • If you think you are depressed, it is important to ask for help. Your parents and others who care about you may not know enough about depression to recognize it. Tell your parents, teacher, health care provider, or other trusted adult about your feelings so they can help you get the help you need to feel better. Depression is not your fault and you didn't do anything to cause it. You don't have to feel this way!
  • When you’re feeling “down” or depressed, you may want to be by yourself and withdraw from family and friends, but isolating yourself is not a good thing to do. It is better to stay connected with those who love you and care about you. Spend time with friends and family and stay involved in social activities even when you have to force yourself to do so.
  • Perhaps you think that talking about your feelings will make you feel worse. Actually, it’s just the opposite— sharing your worries and concerns with someone who will listen and care can often make you feel at least a little bit better.
  • Don't use alcohol or drugs to try to escape your feelings or feel better. Substance use can actually make you feel worse and can also cause you to have suicidal feelings.

For Parents

  • All teens have good days and bad days. Brief periods of sadness or irritability in response to disappointment or loss are a normal part of growing up and usually go away in a short time. However, sadness and crying that last for two weeks or more may be symptoms of depression.
  • Sadness is not the only sign of depression. Other signals that your teen may be depressed include:
    • Antisocial behavior
    • Diminished school performance
    • Withdrawal from friends and social activities
    • Substance Abuse (alcohol, drugs)
    • Aggression
    • Agitation or irritability
  • Loss of interest or pleasure in activities
  • Too much or too little sleep
  • Excessive weight gain or loss
  • Neglect of appearance
  • Difficulty concentrating or making decisions
  • Feelings of worthlessness, guilt or anger
  • Depressed teens often do not realize that they need help or that help is available. They may have a hard time telling someone about how they are feeling. If you see signs that your teen may be depressed, talk to her about what you’re seeing. Let her know that you care and want to help her. You may not have the answers to her problems, but you can make sure she gets the help she needs. Just showing an interest in her feelings might offer her hope when she is feeling hopeless.
  • Try to get her to remain connected to family and friends. Don’t let her isolate herself if at all possible. Encourage her to get some exercise—any form of physical activity can help. Something as simple as a short walk can help to improve her mood and ease her pain.
  • Tell her health care provider about your concerns about her behavior, moods, or mental health. Ask for resources and referrals.
Resources for Providers, Teens, and Families

For Providers

Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities

Screening for Depression Across the Lifespan: A Review of Measures for Use in Primary Care Settings

Screening and Treatment for Major Depressive Disorder in Children and Adolescents

Improving Early Identification & Treatment of Adolescent Depression: Considerations & Strategies for Health Plans PDF


Incorporating Mental Health Checkups Into Adolescent Visits at Rural Health Clinics PPT

Mood Disorders: Depressive and Bipolar Disorders PDF

Depression in Children and Adolescents: A Fact Sheet for Physicians

Major Depression in Children and Adolescents

Bright Futures Case Studies for Primary Care Clinicians: Depression - Too Tired to Sleep

For Teens

Change Your Mind about Mental Health:
Learning from your peers: Jason's story (pg.4)

Working Toward Wellness

Is It Just a Mood or Something Else

For Families

Symptoms of Depression in Adolescents PDF

The Depressed Child

Child & Adolescent Bipolar Foundation

National Depressive and Bipolar Support Alliance

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