Pediatrics · Year 3 · from Pediatrics

Case 1: Adolescent Depression with Suicidal Ideation

Patient Demographics

  • Age: 15-year-old female
  • Sex: Female

Chief Complaint

"I'm here for my sports physical."

History of Present Illness

A 15-year-old girl presents for a preparticipation sports physical for the upcoming soccer season. Her mother is in the waiting room. When interviewed alone, the patient appears withdrawn and makes limited eye contact. During the HEADSS assessment, she discloses that she has been feeling "sad and empty" for the past 3 months. She has difficulty falling asleep, often lying awake until 2 AM thinking about "everything that's wrong." She has lost interest in soccer and hanging out with friends. Her grades have dropped from As and Bs to Cs and Ds. She admits to thinking "everyone would be better off without me" and has thought about taking pills from her mother's medicine cabinet. She denies a specific plan or intent to act. She denies substance use. Her parents divorced 6 months ago, and she feels caught in the middle.

HEADSS Assessment Summary

  • Home: Parents divorced 6 months ago; lives with mother; feels caught in the middle of parental conflict
  • Education: Junior in high school; grades dropped significantly this semester
  • Eating: Decreased appetite, lost 8 lbs over 2 months
  • Activities: Withdrew from friends; stopped attending soccer practice
  • Drugs: Denies tobacco, alcohol, or drug use
  • Sexuality: Has a boyfriend of 4 months; sexually active with condoms; denies abuse or coercion
  • Suicide/Safety: Passive suicidal ideation (thoughts that others would be better off without her); has thought about method (pills) but denies current intent or plan

PHQ-A (Patient Health Questionnaire - Adolescent)

  • Score: 18/27 (moderately severe depression)
  • Positive for nearly every day: feeling down, sleep problems, fatigue, worthlessness, concentration difficulty
  • Reports some thoughts of self-harm

Physical Examination

  • Vital Signs: HR 72 bpm, BP 110/68 mmHg, Weight: 52 kg (down from 56 kg 4 months ago)
  • General: Appears tired, poor eye contact, slow to respond to questions, flat affect
  • Skin: No evidence of self-harm (cutting); intact without lesions
  • Cardiovascular: Normal
  • Otherwise: Normal examination appropriate for sports clearance

Diagnosis

Major depressive disorder, moderate to severe, with suicidal ideation

Clinical Reasoning

This adolescent meets DSM-5 criteria for major depressive disorder with depressed mood and multiple additional symptoms (sleep disturbance, loss of interest, decreased energy, worthlessness, poor concentration, weight loss) present for more than 2 weeks, causing significant functional impairment (grades, social withdrawal). The suicidal ideation with thoughts of method but without current intent places her at moderate risk requiring careful safety planning. Precipitating stressor (parental divorce) is identified but does not diminish the severity of the disorder. The presentation at a "sports physical" is typical - adolescents often do not self-identify depression and may only disclose when specifically asked during confidential screening.

Management

  1. Risk assessment: No imminent risk given lack of plan/intent, but requires safety planning
  2. Safety planning:
  • Identify warning signs and coping strategies
  • List trusted adults she can contact
  • Remove access to lethal means (discuss medication lockbox with parent)
  • Provide crisis line information (988 Suicide and Crisis Lifeline)
  1. Parental involvement: With patient's agreement, involve mother in safety planning; emphasize means restriction
  2. Psychotherapy referral: Cognitive behavioral therapy (CBT) or interpersonal therapy - first-line treatment
  3. Medication consideration: Given severity, discuss starting fluoxetine (FDA-approved for adolescent depression) 10 mg daily
  4. Black box warning counseling: Discuss increased monitoring for suicidal ideation with SSRI initiation
  5. Close follow-up: See in 1 week; more frequent contact during first month of medication
  6. Sports clearance: Defer pending mental health stability

Clinical Image

Image Description: Sample Patient Health Questionnaire for Adolescents (PHQ-A) used for depression screening, demonstrating the scoring system and key questions about mood, sleep, and suicidal thoughts.

Source: Wikimedia Commons - Mental Health Screening URL: https://commons.wikimedia.org/wiki/File:Depression_screening.svg License: CC BY-SA 4.0

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