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.
For the intern
At 3am, your priorities are assessing immediate safety: screen for active suicidal ideation with plan and intent, evaluate for psychotic symptoms, and determine if the patient poses a danger to self or others. Document a safety plan and psychiatric consultation if needed. Routine depression or anxiety screening, medication initiation, and therapy referrals can wait until morning rounds or follow-up visits. Universal screening at well visits should be built into your workflow during daytime clinic hours.
Common pitfalls
- Forgetting the black box warning: Children and adolescents on selective serotonin reuptake inhibitors (SSRIs) require close monitoring for increased suicidality in the first 4-8 weeks of treatment. Schedule early follow-up and counsel families about warning signs.
- Missing bipolar disorder: Always screen for manic symptoms before starting antidepressants. Unipolar treatment of bipolar depression can precipitate mania. Ask about periods of decreased need for sleep, racing thoughts, or impulsive behavior.
- Treating older adults like younger adults: Start medications at half the usual adult dose ("start low, go slow"). Avoid tricyclic antidepressants and paroxetine due to anticholinergic effects and cognitive impairment risk.
- Not following up: The highest risk period is the first 1-2 weeks after diagnosis or medication initiation. Schedule close follow-up and reassess with validated tools like Patient Health Questionnaire-9 (PHQ-9) or Generalized Anxiety Disorder-7 (GAD-7) at every visit.
Make it stick
You’re seeing Sarah, a 16-year-old, for her annual physical. She’s been withdrawn lately, spending more time in her room, and her grades have slipped. You administer the PHQ-A, and her score is 18. You ask about suicidal ideation, and she admits to passive thoughts but no plan. You discuss therapy and medication, starting her on fluoxetine. You schedule a follow-up in one week and provide crisis line information. Her mom is grateful you asked. Six months later, Sarah is doing well, back to her old self, and thanks you for listening. This is why we screen.
If you remember one thing
Screening for depression and anxiety across all ages is crucial for early identification and intervention, improving long-term outcomes and saving lives. Always assess for suicide risk directly when screening is positive, and remember age-specific presentations and treatment considerations.