What is the recommended diagnosis and treatment approach for adolescents presenting with mental health concerns, including depression, anxiety, and substance use disorders?

Diagnosis and Treatment of Mental Health Concerns in Adolescents

All adolescents aged 12-21 years should be screened annually for depression using a formal self-report screening tool, and those with positive screens, emotional complaints, or risk factors must be evaluated using DSM-5 diagnostic criteria for major depressive disorder, anxiety disorders, and substance use disorders. 1

Universal Screening Protocol

Screen all adolescents ages 12-21 years annually for depression using validated self-report instruments either on paper or electronically, regardless of presenting complaint. 1 This universal screening approach is essential because lifetime prevalence of depression reaches approximately 20% by age 20, and most affected youth go unidentified without systematic screening. 1

Screen specifically for substance abuse, depression, anxiety, and other mental health disorders at least annually during preventive health visits. 1 The American Academy of Pediatrics developed freely available screening resources including the Level 1 Cross-Cutting Symptom Measures to efficiently gather information about multiple psychiatric disorders. 1

Targeted High-Risk Screening

Identify and systematically monitor adolescents with depression risk factors using formal depression instruments, including those with: 1

• Previous depressive episodes or family history of depression, bipolar disorder, or suicide-related behaviors
• Other psychiatric disorders or substance use
• Trauma history, physical or sexual abuse, neglect
• Significant psychosocial stressors or family crises
• Frequent somatic complaints
• Foster care or adoption status
• Previous high-scoring screens without depression diagnosis

Diagnostic Evaluation for Positive Screens

Evaluate all adolescents who screen positive, present with emotional complaints, or have high clinical suspicion despite negative screens by assessing depressive symptoms based on DSM-5 criteria. 1 A major depressive episode requires prominent depressed or dysphoric mood nearly every day for at least 2 weeks that interferes with daily functioning, plus at least 5 of these symptoms: depressed mood, loss of interest, significant weight/appetite change, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, guilt or worthlessness, impaired concentration, or suicidal ideation. 1, 2

Recognize that adolescents frequently present with irritability rather than depressed mood as the main manifestation, and may show oppositional or negative behavior, persistent boredom, poor school performance, frequent absences, or preoccupation with song lyrics suggesting life is meaningless. 1

Obtaining Collateral Information

Obtain information from multiple sources including parents, teachers, school personnel, and mental health clinicians to document symptoms and impairment across more than one major setting (social, academic, occupational). 1, 3 For adolescents with multiple teachers, attempt to obtain reports from at least 2 teachers or alternative sources such as coaches, school guidance counselors, or community activity leaders. 1

Recognize that adolescents' self-reports often differ from other observers because they tend to minimize their own problematic behaviors, making collateral information essential. 1

Mandatory Comorbidity Assessment

Screen for all comorbid conditions simultaneously including: 1, 3

• Emotional/behavioral conditions: anxiety, depression, oppositional defiant disorder, conduct disorders, substance use disorders
• Developmental conditions: learning disabilities, language disorders, autism spectrum disorders
• Physical conditions: tics, sleep apnea, chronic medical illness

At minimum, assess adolescents with newly diagnosed mental health concerns for symptoms of substance use, anxiety, depression, and learning disabilities, as these common comorbidities significantly affect treatment approach and worsen outcomes when untreated. 1, 3, 4

Critical Adolescent-Specific Assessments

Establish that symptoms had onset or manifestations before age 12 years through documented or reliably reported history, as this is required for certain diagnoses like ADHD and helps differentiate primary from secondary conditions. 1

Assess for suicidal ideation, physical and sexual abuse, bullying, substance use, and sexual orientation at well-adolescent visits and when any psychosocial or adaptive difficulties are evident. 1

Evaluate suicide risk by determining intent, which is key in risk determination. High-risk indicators include: plan or recent attempt with high lethality probability, stated current intent, recent suicidal ideation with agitation or severe hopelessness, and impulsivity with profoundly dysphoric mood associated with bipolar disorder, major depression, psychosis, or substance use disorder. 1

Substance Use Disorder Diagnosis

Recognize that substance use problems exist on a continuum from subdiagnostic substance use problems (SUP) to substance use disorders (SUD), with adolescents with SUP showing increased psychiatric symptoms compared to those with no/nonproblematic use. 5 Adolescents may be diagnosed with substance abuse, substance dependence, or substance use disorder not otherwise specified. 6

Screen for substance use disorders as psychiatric comorbidity is the rule rather than exception, with common comorbidities including depression, anxiety, bipolar disorder, conduct disorder, and ADHD. 6 Girls with SUP or SUD have increased odds of mania, ADHD, and conduct disorder symptoms; girls with SUD are at increased risk for depression, eating disorders, and hallucinations. Boys with SUP have increased odds of ADHD symptoms, while boys with SUD have increased odds of hallucinations and delusions. 5

Anxiety Disorder Diagnosis

Differentiate clinically significant anxiety disorders from normative developmental worries and fears by assessing whether anxiety is developmentally inappropriate, excessive, and causes significant distress or functional impairment. 1 DSM-5 anxiety disorders include separation anxiety (8 subcategories), selective mutism, specific phobia, social anxiety, panic disorder, agoraphobia, generalized anxiety disorder, substance/medication-induced anxiety, and anxiety due to medical conditions. 1

Use the DASS-21 total score with cut-off ≥44 for detecting any internalizing disorder in substance use treatment settings, which provides sensitivity of 0.81, specificity of 0.62, and positive predictive value of 0.80. 7

Treatment Approach Based on Diagnosis

Depression Treatment

Initiate treatment with fluoxetine 10-20 mg/day for adolescents with major depressive disorder, as fluoxetine is FDA-approved for children aged 8 years and older. 2 Start with 10 mg/day for one week, then increase to 20 mg/day. For lower weight children, the starting and target dose may remain 10 mg/day, with dose increase to 20 mg/day considered after several weeks if insufficient improvement. 2

Recognize that full therapeutic effect may be delayed until 4 weeks of treatment or longer, and doses above 20 mg/day may be administered once daily (morning) or twice daily (morning and noon), not exceeding maximum of 80 mg/day. 2

Monitor appropriately for clinical worsening, suicidality, or unusual changes in behavior when starting antidepressant therapy, as required by FDA boxed warning. 1

Comorbid Condition Treatment Sequencing

When depression and other conditions are comorbid, treat depression first if it is the primary disorder or has severe symptoms. 3, 4 For comorbid anxiety disorders, treat the anxiety disorder until clear symptom reduction is observed before treating other conditions, although combined treatment may also be appropriate. 3, 4

Prioritize treatment of active substance use disorders before initiating stimulants for comorbid ADHD, and address severe mood symptoms requiring stabilization. 8

Psychosocial Interventions

Implement evidence-based psychotherapy approaches including cognitive-behavioral therapy for anxiety and depression, and parent training in behavior management for younger children with behavioral concerns. 3 Collaborative care using care managers to link primary care providers, patients, and mental health specialists is effective for depression. 1

Establish mental health referral and collaboration resources in the local community to ensure timely access to needed services, as most adolescents requiring mental health treatment are not receiving care. 1

Chronic Care Management

Manage adolescents with mental health conditions following chronic care model principles and medical home approach, with periodic re-evaluation of treatment effectiveness and ongoing monitoring for emergence of new comorbid conditions throughout the lifespan. 1, 3, 8 Most psychiatric disorders present during childhood or adolescence, and 74% of 21-year-olds with mental disorders had previous problems. 1

Recognize that lack of treatment results in worsening symptoms, disability, interpersonal difficulties, poor school performance, and increased lifetime risk, with psychiatric illnesses associated with over 50% of disability-adjusted life-years for ages 15-44. 1

Common Pitfalls to Avoid

Do not rely solely on adolescent self-report, as adolescents tend to underreport psychological distress and minimize problematic behaviors—always obtain collateral information from parents and teachers. 1, 9

Do not assume absence of current suicidal ideation indicates low risk after a suicide attempt if factors leading to the attempt have not changed or are not understood. 1

Do not overlook that certain substances like marijuana can mimic ADHD symptoms, and adolescents may feign symptoms to obtain stimulant medication for performance enhancement. 1

Do not treat mental health conditions in isolation—the high comorbidity burden requires simultaneous assessment and coordinated treatment of all conditions. 3, 4