Screening Tools for Adolescent Depression and Bipolar Disorder
Depression Screening in Adolescents (Ages 12-18)
The PHQ-9 with a cutoff score of 11 is the most validated and recommended depression screening tool for adolescents aged 12-18 years in primary care settings. 1
Primary Screening Options
PHQ-9 (Patient Health Questionnaire-9) is the gold standard, demonstrating sensitivity of 89.5% and specificity of 77.5% when validated against structured diagnostic interviews (DISC-IV) at a cutoff of 11. 1
PHQ-2 (2-item version) can serve as a brief initial screen with sensitivity of 73.7% and specificity of 75.2% at a cutoff score of 3, though it is less accurate than the full PHQ-9. 1
Mood and Feelings Questionnaire (MFQ) is specifically validated for adolescents aged 12-18 years and represents an alternative to the PHQ-9, though it cannot reliably discriminate depression in children below age 13. 2
Beck Depression Inventory (BDI) primary care version has been studied extensively in adolescents alongside the PHQ-A. 1
Screening Strategy
Use the PHQ-9 directly rather than a two-step approach (PHQ-2 followed by PHQ-9), as the dimensional algorithm of the PHQ-9 demonstrates superior validity with an area under the curve of 93.2% compared to 87.2% for the PHQ-2. 3
Avoid the categorical algorithm of the PHQ-9 (which uses DSM criteria), as it yields unacceptably low sensitivity of only 52.5% despite high specificity of 94.7%. 3
Screen all adolescents aged 12-18 years universally, as recommended by the USPSTF, not just those with risk factors. 1
Critical Implementation Requirements
Only implement screening if your practice has systems ensuring accurate diagnosis, effective treatment, and careful follow-up. 2
A positive screen requires a full diagnostic interview using DSM criteria to confirm depression—screening tools are not diagnostic instruments. 2
Unaided clinical recognition without screening tools has a sensitivity of only 12.5%, demonstrating why systematic screening is essential. 3
Important Caveats
Avoid multidimensional screening tools that combine depression with other behavioral health issues, as evidence suggests too much information may overwhelm clinicians and result in positive depression screens being overlooked. 1
Paper, internet-based, and electronic screening methods appear equally effective—choose based on practice workflow rather than perceived superiority of one format. 1
Brief depression screens may miss suicide risk questions—ensure your chosen tool includes suicide assessment or add it separately. 1
Depression Screening in Children (Ages 11 and Younger)
Evidence is insufficient to recommend for or against depression screening in children aged 11 years or younger. 1
The USPSTF assigns an "I" statement (insufficient evidence) for this age group, as data on screening accuracy and treatment benefits are inadequate. 1
The mean age of onset for major depressive disorder is 14-15 years, making depression less prevalent in younger children. 1
Bipolar Disorder Screening in Adolescents
Bipolar disorder screening tools have insufficient accuracy for reliable clinical use in adolescents, even in high-risk populations.
Available Tools with Significant Limitations
Mood Disorder Questionnaire-Adolescent Version (MDQ-A) parent version shows sensitivity of 72-87.5% but specificity of only 57.4-63.2%, with positive predictive values as low as 17.1-21.9%. 4, 5
Child Bipolar Questionnaire (CBQ) demonstrates even worse performance with sensitivity of 50% and specificity of 73.5%, and positive predictive value of only 18.2%. 4
Agreement between adolescent self-report and parent report on the MDQ-A is poor (kappa = 0.07), though parent versions perform slightly better than adolescent self-reports. 4, 5
Clinical Reality of Bipolar Screening
The majority of adolescents who screen positive for bipolar disorder do not meet diagnostic criteria when evaluated with structured interviews like the K-SADS-PL. 4
Screening for bipolar disorder in primary care has unacceptably low positive predictive value and is not sufficiently accurate for routine clinical practice. 6
Screening in high-risk samples (such as adolescents with known depression) is somewhat more successful but still not accurate enough to be used alone. 6
Practical Approach to Bipolar Concerns
Do not use bipolar screening tools as standalone instruments—instead, maintain high clinical suspicion in adolescents with depression who have family history of bipolar disorder, prior manic/hypomanic episodes, or treatment-emergent mania with antidepressants. 4, 5
If bipolar disorder is suspected based on clinical presentation, proceed directly to comprehensive diagnostic evaluation with structured interviews rather than relying on screening tools. 4, 6