Depression in Teenagers: Experts Say to Screen All

Seventeen-year-old Courtney Jones, an aspiring nurse from Portland, Ore., believes that a simple screening test at age 14 saved her life. It was a questionnaire designed to detect mental illness—in her case, depression. "Had I not been screened [for depression]," she states, "I would not be here today."

The subject of depression in teenagers was thrust into the national dialogue recently when a government-appointed panel of medical experts advised that primary-care doctors routinely screen all patients ages 12 to 18 for major depression, an about-face from a 2002 conclusion that there was insufficient evidence to recommend for or against doing so. Now, the U.S. Preventive Services Task Force says in April's Pediatrics, there's "adequate evidence" that screening tests do a good job of accurately detecting depression in teenagers and adolescents—important, it says, since "the majority of depressed youth are undiagnosed and untreated."

"It's very hard for most teens to determine if they are clinically depressed," says Benjamin Van Voorhees, an assistant professor of medicine, pediatrics, and psychiatry at the University of Chicago Medical Center. He led a small study of a Web-based interactive tool called "Project CATCH-IT" that showed promise at helping reduce symptoms of depression in at-risk adolescents by teaching such skills as altering pessimistic thinking, avoiding procrastination, and making a point of doing enjoyable things. Because they're inexperienced, adolescents can find it tricky to sift what's normal from what's not. Maybe they've had a spat with a boyfriend or girlfriend; maybe their mom yelled at them; maybe they've had a series of disappointments in school, and suddenly they're feeling bad and they're not sure if the problems are to blame or if something more is affecting them, Van Voorhees explains. Screening can provide the necessary clues.

That's what happened with Courtney Jones. At the time an eighth grader, she didn't recognize that her evaporating sense of self-confidence, low self-worth, and newfound desire to spend time alone rather than go bowling with friends or camping with her parents were symptoms of depression. "I just convinced myself that I was a typical teenager," she remembers.

It wasn't until Jones agreed to get a mental health checkup at her middle school as part of a voluntary initiative developed by Columbia University researchers that she discovered that she might be experiencing depression. Diagnosed with clinical depression and suicidal thoughts (which progressed to suicide attempts, landing her in the hospital), Jones is doing much better now with a combination of talk therapy and antidepressants. Had it not been for that screening and the help she got as a result, "we would have lost her," says her father, Michael Jones.

An estimated 2 million teens and preteens experience clinical depression each year—at a cost of suffering schoolwork, social isolation, substance abuse, greater risk of pregnancy, and increased suicide risks. Ned Calonge, chair of the U.S. Preventive Services Task Force and chief medical officer for the Colorado Department of Public Health and Environment, says: "The fact that we can identify these kids through screening, then effectively treat them in terms of improving their health status, is why we think this is a worthwhile recommendation for all kids." Screening everyone as a routine part of the annual physical, just like checking blood pressure, is the most effective approach, he adds, because it will ensure that those without obvious symptoms or risk factors such as a family history of depression don't slip by.

James McGhee, a pediatrician in Nevada, would like that to see that happen. "If parents didn't say directly to me, 'I think my child has a problem with such and such,' I often never spent a lot of time on the path of mental health," he reflects. "I asked a few basic questions—'Have you ever thought of killing yourself?'—and then moved on.' " But when he recently began screening for depression in his teenage patients as part of a study aided by the same group that screened Jones, he started identifying adolescents he might have otherwise overlooked.

The new recommendation comes with a serious caveat: that adolescents should be screened only "when systems are in place to ensure accurate diagnosis, psychotherapy, and follow-up," the panel said. Otherwise, says Calonge, "you just identify the problem and you haven't done anything [else]. Plus, we don't want people just pulling out the prescription pad, because there's a concern that [medication] may do more harm than good; we're just worried about that." Calonge's group found "convincing evidence" that a commonly prescribed class of antidepressants—selective serotonin reuptake inhibitors [SSRIs]—can raise the risk of suicidal thoughts or actions in adolescents, which is why the task force urged that those drugs, though often effective, should be considered only when young patients can be closely supervised.

Since news of the screening recommendation broke, the Internet has been abuzz with impassioned comments from people concerned that universal screening will lead to overdiagnosis, even misdiagnosis. One writes, "If you screen every teen for depression there will be one result: All teens are depressed." Calonge says there's little chance of that happening.

Parents shouldn't assume that their child's mental health is being assessed during routine checkups. There are several factors that may hamper widespread implementation of the new recommendation: For one thing, primary-care doctors may not feel prepared to handle their young patients' mental health issues, says Van Voorhees. And mental health professionals trained to diagnose and treat children and adolescents are in short supply and often have lengthy waiting lists, which can make referral tricky.

So parents remain a necessary early warning system. "If you see your kid having some impairment, having some symptoms, by all means get them to someone who can help," says Oscar Bukstein, a child and adolescent psychiatrist and an associate professor of psychiatry at the University of Pittsburgh School of Medicine. "If you look at the natural history of depression, you find that there's a marked increase in the onset of depression in adolescence, post-puberty," he says, "and that many, if not most people who have recurrent depression will often point to adolescence as a point of onset." Roughly half of all mental illnesses arise by age 14, as Jones's did. Finding kids like her is bound to save lives.