# Depression and Anxiety Screening Across Ages

## Introduction

Depression and anxiety are the most prevalent mental health conditions worldwide, affecting all age groups from preschool-aged children to older adults. The USPSTF recommends **universal screening for depression** in adults, adolescents, and children aged 8 and older. Med-peds physicians are often the first point of contact and must integrate mental health screening into routine primary care across the lifespan.

## Epidemiology

**Children (3-12 years)**: Anxiety prevalence ~7%; depression ~3%. **Adolescents (13-18 years)**: Depression ~13%; anxiety ~32%. **Adults (18-64 years)**: Major depressive disorder lifetime prevalence ~17%; generalized anxiety ~6%. **Older adults (65+)**: Depression ~7% in community settings, up to 30% in nursing homes. Suicide is the **second leading cause of death** in ages 10-34.

## Screening Tools by Age

### Children (Ages 8-12)
**PHQ-9 Modified for Adolescents (PHQ-A)**: Can be adapted for older children. **Screen for Child Anxiety Related Disorders (SCARED)**: 41-item parent and child report. **Pediatric Symptom Checklist (PSC)**: Broad psychosocial screening.

### Adolescents (Ages 12-18)
**PHQ-A**: 9-item depression screening tool. **GAD-7**: Generalized anxiety screening. **Columbia Suicide Severity Rating Scale (C-SSRS)**: For suicide risk assessment. Screening recommended at **every annual well visit** (AAP, USPSTF)

### Adults (Ages 18-64)
**PHQ-9**: Gold standard for depression screening; score 10+ suggests moderate depression. **GAD-7**: Score 10+ suggests moderate anxiety. **PHQ-2**: Two-item rapid screen; if positive, follow up with PHQ-9. **Edinburgh Postnatal Depression Scale (EPDS)**: For perinatal depression.

### Older Adults (65+)
**Geriatric Depression Scale (GDS)**: 15 or 30-item version designed for elderly. **PHQ-9**: Also validated in older adults. Screen for depression in context of medical illness, bereavement, cognitive decline.

![Table of validated screening tools by age group](images/depression-screening-tools.jpg)

## Age-Specific Presentations

### Children
Irritability more common than sadness; Somatic complaints (headache, stomachache); School refusal, social withdrawal; Separation anxiety, specific phobias are the most common anxiety disorders.

### Adolescents
Mood lability, anger, risk-taking behavior; Academic decline, social isolation; Self-harm, suicidal ideation; Social anxiety disorder often emerges in this age group.

### Adults
Classic depressive symptoms: persistent sadness, anhedonia, sleep and appetite changes. Anxiety may present as worry, restlessness, muscle tension, palpitations; Comorbid substance use is common; Work and relationship dysfunction.

### Older Adults
**Pseudodementia**: Depression mimicking cognitive impairment. Somatic focus: fatigue, pain, GI symptoms; Apathy and withdrawal rather than expressed sadness; High suicide completion rate despite lower attempt rate.

## Diagnostic Considerations

### Differential Diagnosis
Thyroid disease (hypo- or hyperthyroidism); Anemia; Substance use or medication side effects; Chronic medical conditions (diabetes, heart failure, cancer); Bipolar disorder (screen before initiating antidepressants); ADHD (overlapping symptoms with anxiety in children).

### When to Refer
Suicidal ideation with plan or intent; Psychotic features; Bipolar disorder; Treatment-resistant symptoms (failed 2+ adequate trials); Severe functional impairment.

![Flowchart for depression screening and management pathway](images/depression-management-pathway.jpg)

## Treatment Overview

### Non-Pharmacologic
**Cognitive Behavioral Therapy (CBT)**: First-line across all ages. Interpersonal therapy (IPT): Effective for adolescent and adult depression; Behavioral activation; Mindfulness-based interventions; Exercise prescription (150 minutes/week moderate activity).

### Pharmacologic

| Age Group | First-Line | Considerations |
|---|---|---|
| Children 8-12 | Fluoxetine + CBT | FDA black box warning; close monitoring |
| Adolescents | Fluoxetine, escitalopram | Monitor for suicidality in first 4-8 weeks |
| Adults | SSRIs (sertraline, escitalopram) | Trial duration 4-6 weeks; augmentation if partial response |
| Older adults | Sertraline, escitalopram | Start low, go slow; avoid TCAs and paroxetine |
| Perinatal | Sertraline | Weigh risks vs. benefits; untreated depression carries fetal risks |

### Monitoring
Follow-up within 1-2 weeks of initiating medication. Reassess with validated tool (PHQ-9/GAD-7) at each visit. Continue treatment for at least 6-12 months after remission. Discuss taper plan; relapse risk is highest in first 6 months after discontinuation.

![Graphic showing the stepped care model for depression management](images/stepped-care-depression.jpg)

## Clinical Pearls

Screen for depression at every well-child visit starting at age 12 and at every adult visit; it takes less than 2 minutes. A positive PHQ-2 should always be followed by the full PHQ-9. Always assess for **suicidality** when depression is identified; ask directly and document a safety plan. Avoid monotherapy with antidepressants in children and adolescents; CBT plus medication is superior to either alone. In older adults, somatic complaints may be the primary manifestation of depression; maintain a high index of suspicion.

## References

1. Siu AL, US Preventive Services Task Force. Screening for depression in children and adolescents: US Preventive Services Task Force recommendation statement. *Pediatrics*. 2016;137(3):e20154467.
2. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. *J Gen Intern Med*. 2001;16(9):606-613.
3. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression (TADS). *JAMA*. 2004;292(7):807-820.
4. Alexopoulos GS. Depression in the elderly. *Lancet*. 2005;365(9475):1961-1970.