Signs of Depression in Teenagers
Teenagers with depression frequently present with irritability rather than sadness, and clinicians must actively look for behavioral manifestations including oppositional behavior, loss of interest in previously enjoyed activities, academic decline, and physical complaints rather than expecting the classic depressed mood seen in adults. 1
Core Mood Symptoms
- Irritable or cranky mood is often the primary manifestation in adolescents, rather than the sad or depressed mood typical of adults 1
- Depressed or down feelings most of the time, with crying spells 1
- Preoccupation with song lyrics suggesting life is meaningless 1
- Feelings of worthlessness or inappropriate guilt 1
Behavioral Changes
- Loss of interest in sports, video games, and activities with friends that were previously enjoyed 1
- Oppositional and/or negative behavior patterns 1
- Talk of running away from home or actual attempts to do so 1
- Social withdrawal and isolation from peers 2
- Bullying or aggressive behavior 2
Academic and Cognitive Signs
- Poor performance in school with declining grades 1
- Frequent school absences 1
- Diminished ability to think or concentrate 1
- Indecisiveness 1
- Persistent boredom 1
Physical Manifestations
- Frequent complaints of physical illness, particularly headaches and stomach aches 1
- Significant weight loss or gain, or failure to make expected weight gains 1
- Changes in appetite (anorexia or bulimia patterns) 1
- Multiple somatic complaints in a physically healthy child 2
Sleep Disturbances
- Excessive late-night television watching 1
- Refusal to wake for school in the morning 1
- Insomnia or hypersomnia nearly every day 1
Energy and Activity Changes
- Fatigue or loss of energy nearly every day 1
- Psychomotor agitation or retardation observable by others 1
Critical Warning Signs Requiring Immediate Action
- Recurrent suicidal ideation or behavior, including threats of suicide 1, 3
- Writing about death or dying 1
- Giving away favorite toys or belongings 1
- Recurrent thoughts of death (not just fear of dying) 1
Important Clinical Caveats
A critical pitfall is dismissing irritability, oppositional behavior, or physical complaints as "typical teenage behavior" rather than recognizing these as potential manifestations of depression. 1 Adolescents may have difficulty identifying and describing internal mood states, making behavioral observation essential. 4
Depression screening is now recommended annually for all adolescents ages 11-21 years using validated instruments like the PHQ-9 Modified for Teens. 1, 5, 6 The American Academy of Pediatrics emphasizes that screening should occur not only at well visits but also at acute care visits when mental health problems may manifest more strongly. 1
When any signs are present, direct questioning about suicidal ideation should be embedded within the assessment: "Have you ever thought about killing yourself or wished you were dead?" followed by "Have you ever done anything on purpose to hurt or kill yourself?" 1, 5 Safety takes precedence over confidentiality when adolescents are at risk to themselves. 1, 3