What questions should be asked during a psych evaluation to assess moods and behaviors in adolescent kids prior to prescribing medications like fluoxetine (selective serotonin reuptake inhibitor - SSRI)?

Key Questions for Adolescent Psychiatric Evaluation Prior to SSRI Medication

When evaluating adolescents for mood disorders prior to prescribing medications like fluoxetine, clinicians should use a structured approach that includes specific screening questions for depression, suicidality, and comorbid conditions.

Depression Screening Questions

Core Mood Assessment

• "Have you ever felt so upset that you wished you were not alive or wanted to die?" 1
• "Did you ever do something that you knew was so dangerous that you could get hurt or killed by doing it?" 1
• "Did you ever hurt yourself or try to hurt yourself?" 1
• "Did you ever try to kill yourself?" 1
• "Did you ever think about or try to commit suicide?" 1

Mood Changes and Symptoms

• Ask about distinct periods of mood changes associated with sleep disturbances and psychomotor activation 1
• Assess for irritability rather than depressed mood as the main manifestation in adolescents 1
• "Aside from [already stated non-mental health concern], how have you been doing?" 1
• "What kinds of things have been on your mind or stressing you lately?" 1
• "How have things been going with [school, friends, parents, sports]?" 1

Validated Screening Tools

Recommended Screening Instruments

• Patient Health Questionnaire-9: Modified for Teens (PHQ-9) with a cut-point of 11 (sensitivity 89.5%, specificity 77.5%) 1
• Patient Health Questionnaire-2 (PHQ-2) with a cut score of 3 (sensitivity 73.7%, specificity 75.2%) 1

Suicide Risk Assessment

Suicide Intent Evaluation

• Assess suicide plans: "If you were to kill yourself, how would you do it?" 1
• Determine if there are firearms in the home 1
• Evaluate the family's response to suicidal thoughts 1
• Assess motivating feelings (attention-seeking, desire to change relationships, wish to rejoin deceased relatives, escape from intolerable situations, revenge) 1

Risk Factors for Suicide

• Previous suicide attempts 1
• Male gender 1
• Increasing age 1
• Living alone (runaway, homeless, isolated) 1
• Attempts with methods other than ingestion or superficial cutting 1
• Steps taken to avoid detection 1

Bipolar Disorder Screening

Bipolar Symptoms

• Screen for distinct, spontaneous periods of mood changes with sleep disturbances and psychomotor activation 1
• Assess for family history of mood disorders 1
• Evaluate symptoms of irritability, reckless behaviors, or increased energy 1
• Look for manic grandiosity and irritability that present as marked changes in mental/emotional state 1

Pre-Medication Assessment

Treatment Considerations

• For moderate to severe depression, combination treatment with medication and psychotherapy is recommended 2
• Fluoxetine is the first-line SSRI for adolescents with major depressive disorder 2, 3
• Initial dosing for adolescents should be 10 mg daily for 1 week, then increased to 20 mg daily 3
• Weekly monitoring during the first 4 weeks of treatment is essential 2

Important Clinical Pearls

Diagnostic Pitfalls

• Manic-like symptoms of irritability and emotional reactivity may be found in multiple conditions, including disruptive behavior disorders, PTSD, and pervasive developmental disorders 1
• Behavioral and emotional reactions to psychosocial stressors may be mistaken as symptoms of an underlying biological illness 1
• Adolescents may disclose information about suicidality on self-report that they deny in person 1

Confidentiality Considerations

• Although confidentiality is important in adolescent health care, safety takes precedence over confidentiality for adolescents at risk to themselves or others 1
• Explain to the adolescent that confidentiality has limits when safety is concerned 1

Follow-up Planning

• Plan for weekly monitoring during the first 4 weeks of treatment 2
• Use standardized symptom rating scales to track progress 2
• Monitor for adverse effects, particularly suicidal ideation/behavior and activation syndrome 2

By using this structured approach to psychiatric evaluation, clinicians can thoroughly assess adolescents' mood and behavior before initiating SSRI treatment, ensuring appropriate diagnosis and treatment planning while prioritizing patient safety.