AAP Guideline: Screen All Teens for Depression and Suicide Risk

Hansa Bhargava, MD: I am Hansa Bhargava, a practicing pediatrician and senior medical director at Medscape and WebMD. Earlier this year, the American Academy of Pediatrics (AAP) published updated guidelines for identification and management of depression in adolescents.^[1,2] The guidelines are aimed at youth ages 10-21 years and distinguish the differences between mild, moderate, and severe forms of major depressive disorder. For the first time, the guidelines also endorse a universal adolescent depression screening for children age 12 and older.

I am delighted today to be speaking with Dr Colleen Kraft, president of the AAP, about the new guidelines and, in particular, the issue of identification. Colleen, we are all aware that depression is a growing concern for our teens, but how much of a concern? Would you give us an overview?

Colleen A. Kraft, MD, MBA: We know that about 1 in 5 adolescents suffer from depression, but what we haven't had is a strategy to screen them, to identify them, to see whether this is a major or minor problem, and to understand how to manage it. We know now that we can accomplish this in a primary care setting. Pediatrics has become the place where we screen our adolescents, where we can make that diagnosis, where we can refer them on to some brief therapy, and where we can find answers for those adolescents and perhaps begin to prescribe therapy and follow-up.

Bhargava: Why do you think depression is such an issue in our teens? I know the rates have gone up. Is it that we are diagnosing it earlier? Or is it because we have less access to care? What are your thoughts?

Kraft: The rates of depression have gone up, but I believe it is because we are identifying more children, and that is a good thing. Once we are able to identify these young people with depression, then we can talk with them and normalize their feelings while letting them know that there is a way out of this. We can start with counseling. If needed, we can begin different therapies and even medication. And we can follow up to see how they are doing and how they are progressing with treatment.

Bhargava: You have a particular interest in the identification of depression in high-achieving children who are often subject to much anxiety and pressure. Is this a new phenomenon or is this something that has been lying under the surface?

Kraft: Unfortunately, we are seeing an increase in the number of high-achieving kids with depression. These are the star athletes and the scholars who are victims of suicide. We are asking ourselves how we can use these guidelines to enable us to talk with families and these children and identify what may be an unrealistic perfectionism, or an isolation related to the need to achieve or the depression, and detecting those risks for becoming a victim of suicide.

Bhargava: Do you believe that high-achieving families would be open to pediatricians talking about these issues when they expect their children to be a certain way? Would they actually accept the diagnosis of depression?

Kraft: I know a teen who recently was a victim of suicide. Her family never saw this coming. A conversation with that adolescent's pediatrician, someone who has been a trusted provider for years, about this being a risk—if it is something that could have identified this possibility earlier—the parents would have been all for it.

Bhargava: It is such an important issue and we are at the front lines. We have those relationships to use as a platform to have the conversation.

Kraft: We know our children. We know what they are doing. We can congratulate them for being high achievers. We also know our partners—the sports psychologists and other therapists in the community—who can talk with our teens about their feelings and how to share them, how to accept small failures, whether they involve a baseball game or a grade. These partners can provide strategies that will help these adolescents build their resilience and attack this whole idea of perfectionism that may lead to them becoming victims of suicide.

Bhargava: Recent statistics show that suicide rates in girls age 10-14 have tripled during the past two decades.^[3] Do you think this is related to increases in depression? Is it anxiety in this society? What has caused this increase?

Kraft: A statistic like that is so alarming that you want to know what is at the bottom of it. It could be a number of factors, including depression. I believe that social media plays a role. If you think about it, 10 or 15 years ago, if someone was depressed or did poorly on a test or flubbed a game, they could talk with their friends. With social media, people are more impulsive, they are less compassionate, and it becomes very isolating for these youngsters.

I believe that social media may play a part in why our younger children are becoming victims of suicide. Moreover, the adolescent brain is developing, and we know that it's not fully developed until the mid-20s. Something that may seem like a temporary setback becomes huge in the minds of these young people and something they cannot seem to get over. That tends to trigger many of these very unfortunate happenings.

Bhargava: As you said, social media amplifies the issue because it follows them around; they cannot get away from it.

Kraft: Right. And finally, if the teenager has access to a firearm or something that can expedite committing suicide, that is a factor. If you are depressed and have a temporary setback, or if you are a high achiever and have a temporary setback, and have access to a firearm, you have a 90% chance of completing a suicide.^[4]

Bhargava: We have talked about the why behind identification. Now let's talk about the how. How as pediatricians can we help these adolescents? The guidelines recommend universal screening. Does the AAP support a specific tool?

Kraft: Several different tools are out there. We allow our pediatricians to use their own clinical expertise to figure out which tool is best for them in their environments. It will be different depending on whether you are talking about a teen in New York, California, Texas, or Montana. But we must screen our teenagers.

Beyond screening, we must talk with our patients. Find out what they are doing, get an idea about what may be going on with them, have an awareness of other things that may be playing into a higher risk for depression or suicide. Is this someone who is struggling with sexual identity? Is this someone who may be experiencing abuse or neglect or bullying? Those are all factors that a screening tool will help you with, but it is the relationship you have that will help you identify the issues and then move that adolescent on to getting help.

Bhargava: All of these areas are so important. As our kids are more "squeezed," with all of these forces around them, it is wonderful that pediatricians are standing up for them. Thank you very much, Dr Kraft, for being here and talking about such an important issue.

Kraft: You are welcome. Thank you.

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