Residency · Residency · Medicine Pediatrics
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.
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.
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.
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
- 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.
- 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.
- 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.
- Alexopoulos GS. Depression in the elderly. Lancet. 2005;365(9475):1961-1970.