“SIGECAPS” mnemonic can help as you evaluate the patient
When you suspect depression, take a detailed history. The diagnostic criteria for depression given in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) are shown in TABLE 1 .7,10,13 Bear in mind, however, that adolescents who do not meet the full criteria may still be quite impaired and in need of help. The SIGECAPS mnemonic (sleep, interest, guilt, energy, concentration, appetite changes, psychomotor agitation or retardation, suicidality) can help you recall the neurovegetative symptoms in the depression criteria.
Ask about bereavement, manic symptoms (eg, feeling irritable/giddy/silly, hyperactive, racing thoughts), substance use, and life stressors. Ask, too, whether the teen has been treated for mental health problems in the past, and if there is any history of physical or sexual abuse or a family history of mental illness. Because depression is often comorbid with other conditions, you should also inquire about other psychiatric disorders, such as ADHD and anxiety disorders.
The next step. When risk factors or checklists alert you to the possibility of depression, the next step is a more formal evaluation. Because teens and parents often feel uncomfortable disclosing information in the presence of the other, separate interviews are a good idea. Information crucial to the diagnosis may be available only from the adolescent or only from the parent or caregiver, and then only if they are interviewed separately.7
Parents may—or may not—pick up on their child’s depression. On the one hand, parents will often have important clues to their child’s diagnosis, such as recent withdrawal from social or extracurricular activities. On the other hand, they may attribute their teen’s behavior to normal adolescent moodiness. Or they might not recognize their teenager’s depression because teens don’t need to be “sad” to be depressed. Sometimes irritability is the major symptom in a depressed teen. (See “How teenage depression is different from that of adults” on page 188.)
Further compounding matters: Since depression is an internalizing disorder, teens may not share their innermost thoughts and emotions with their parents.
How teenage depression is different from that of adults
Teenage depression may not look like adult depression. Teens are more often irritable than sad, and their moods vary with their surroundings (ie, mood reactivity): They may be fine when they’re hanging out with friends, and become depressed again at home or in school. The depressive symptoms they exhibit can range from complaints about stomach aches to fights with family and friends, skipping school, getting poor grades, or substance use.
TABLE 1
Diagnostic criteria for major depressive episode (DSM-IV-TR)
| A. | Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least 1 of the symptoms is either depressed mood or loss of interest.
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| B. | The symptoms do not meet criteria for mixed episode. |
| C. | The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. |
| D. | The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, or a medication) or a general medical condition (eg, hypothyroidism). |
| E. | The symptoms are not better accounted for by bereavement, that is after a loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. |
Is it MDD, or something else?
Although most of the literature on depression is focused on MDD, you should be aware that there are many subtypes of depression, including dysthymia (in which patients have longstanding depressive symptoms but with less functional impairment than major depression) and adjustment disorder (in which patients develop depressive symptoms in response to an acute stressor). As mentioned above, physicians should also assess for psychiatric disorders that are commonly comorbid with depression, because their presence can affect management. These include anxiety disorders, ADHD, eating disorders, and substance abuse.