A falling report card and abandoned soccer practice can make an adolescent depression screen feel like a diagnosis. In a 16-year-old with insomnia, irritability, hopelessness, daily nicotine vaping, and self-injury, the Family Medicine task is more exacting: determine whether the symptoms form a major depressive episode—or reflect another or overlapping condition—without letting a questionnaire score decide.
The presentation deserves careful assessment now. But the available details do not establish how many qualifying symptoms occurred together, how often they were present, or whether another explanation contributes. That uncertainty is a reason to ask better questions, not to dismiss the distress.
Use the screen to open the diagnostic interview
The PHQ-9A can organize symptom review and help track change. It does not independently diagnose major depressive disorder (MDD), establish the cause of symptoms, or determine suicide risk. Once an adolescent is already reporting symptoms, the visit is a clinical evaluation—not simply preventive screening.
MDD requires a distinct period of at least two weeks with five or more of nine symptoms, including depressed or irritable mood, or markedly reduced interest or pleasure. The symptoms must represent a change from baseline and cause clinically significant distress or impairment. The clinician must also consider whether symptoms are better explained by a substance or medical condition, and assess for a history of mania or hypomania.
| Case clue | What it may contribute | What still needs clarification |
|---|---|---|
| Irritability and hopelessness | Irritable mood can be the adolescent presentation of depressed mood | Is the mood change persistent and present most of the day, nearly every day? Hopelessness is not a separate extra symptom to count on top of mood. |
| Loss of interest in soccer | Possible anhedonia | Is interest or pleasure reduced across most activities, or is the change limited to soccer? How frequent and sustained is it? |
| Insomnia and exhaustion | Possible sleep and energy symptoms | Are both a change from baseline, present in the same episode, and sufficiently frequent? |
| Declining school performance | Evidence of functional change or impairment | Ask what changed at school and whether concentration problems are independently present; a lower grade is not itself a separate MDD symptom. |
| Cutting | A behavior that warrants direct assessment | Self-injury alone does not establish suicidal ideation or count automatically as the death-related symptom. Ask what she thought and intended during episodes. |
This symptom-by-symptom check prevents two common counting errors: treating one clue as several symptoms, and counting consequences—such as lower grades—as if they were diagnostic symptoms. Ask about the nine symptom areas directly, then establish whether they cluster in the same two-week period.
Reconstruct the change from baseline
Adolescents may not describe themselves as “sad.” Irritability, sleep changes, fatigue, conflict, and declining school performance can be the clues that prompt a closer assessment. Still, a parent’s description that a teen is “impossible to talk to” does not establish persistent irritable mood; ask the adolescent what the change feels like and when it occurs.
Interview the teen privately, then gather caregiver observations separately when appropriate. A useful timeline includes when sleep, mood, interest, energy, and school functioning changed; what the adolescent’s usual functioning was; and whether symptoms are present at home, school, and with peers. If the story is unclear, permitted collateral information—for example, from school—may help distinguish a sustained decline from a problem limited to one setting.
The wording of PHQ-9 item 9 deserves particular care in this case: it combines thoughts of being better off dead with thoughts of self-harm. An endorsement might refer to thoughts of self-injury without suicidal intent, passive thoughts of death, active suicidal thoughts, or more than one experience. Clarify it directly; do not translate the item’s score into a conclusion about intent. A depression questionnaire is not a stand-alone suicide-risk assessment.
Check for alternatives and overlap before naming the episode
Ask about lifetime periods of unusually elevated or expansive mood, or marked irritability accompanied by increased energy or activity, reduced need for sleep, pressured speech, grandiosity, or risky behavior. A decreased need for sleep is different from lying awake and feeling exhausted. Ask about family history of bipolar disorder as part of the formulation, particularly before considering antidepressant treatment.
Daily nicotine vaping is clinically relevant, but it neither proves nor rules out MDD. Ask when use began, how it relates in time to mood and sleep changes, and whether symptoms change when she cannot vape. A negative urine screen for opioids and amphetamines does not answer questions about nicotine or replace a careful substance history.
Also consider anxiety, trauma or significant stress, ADHD, medication effects, sleep problems, and medical contributors when the history or examination points that way. These possibilities can coexist with depression; the goal is not to find one label that explains every symptom. Choose any medical testing to fit the clinical clues rather than assuming a broad test panel confirms or excludes depression.
Let uncertainty guide follow-up—not false reassurance
If the interview confirms a qualifying symptom cluster, impairment, and no better explanation, MDD may be the appropriate formulation. If the symptom count or timeline remains uncertain, document the symptoms and functional change, provide support, and arrange planned reassessment rather than either forcing the diagnosis or telling the family that nothing is wrong.
Safety needs remain a separate clinical responsibility. Assess the injury and suicidal thoughts directly, regardless of whether the adolescent meets MDD criteria or how the PHQ-9A total scores. Immediate safety concerns should be addressed without waiting for the diagnostic formulation to be complete.
Practical takeaways
- A PHQ-9A score is a starting point for an interview, not an MDD diagnosis or suicide-risk classification.
- Confirm the symptom count, two-week timeframe, change from baseline, and functional impact.
- Treat irritability, sleep change, fatigue, school decline, and self-injury as clues to clarify—not automatic criteria.
- Ask about mania or hypomania, substance use, psychosocial stressors, and medical contributors; overlapping explanations are possible.
