Depression in Children & Adolescents: An Overview for Primary Care Providers (PCPs) in Nevada

Depression or Major Depressive Disorder (MDD) in young people has risen substantially over the past decade and is now a common, treatable condition that PCPs must be prepared to screen for, identify, and manage. Both state and national surveys indicate very high levels of depressive symptoms among adolescents. 

For instance, the CDC’s 2023 Youth Risk Behavior Surveillance (YRBS) data show:

• ~40% of high-school students experience persistent feelings of sadness and hopelessness; 
• ~20% seriously considered attempting suicide;
• ~10% had attempted suicide.

The YRBS report also adds: 

“...data collected during July 2021–December 2022 on the Teen National Health Interview Survey of adolescents aged 12–17 years estimated that 21% of adolescents reported experiencing symptoms of anxiety in the past 2 weeks and 17% reported experiencing symptoms of depression (3).”

As startling as these numbers are, it’s important for PCPs to know that early identification / screening of depression and suicidal ideation combined with timely, evidence-based intervention can reduce morbidity and suicide risk. 

How big is the problem and what are the trendlines — nationally and in Nevada?

Population surveys and clinical datasets show rising diagnosed depression (and other mental health problems) among adolescents. The HRSA’s 2023 National Survey of Children’s Health reports that the prevalence of diagnosed adolescent depression increased substantially from 2016 to 2023 (from ~5.8% to ~8.4% for depression diagnoses), and overall mental-health diagnoses among 12–17 year-olds are now affecting roughly 1 in 5 adolescents nationally. 

Image credit: HRSA’s National Survey of Children’s Health, 2023

Are US adolescents in need able to easily get professional help? Unfortunately, the trendline here is not positive, although we may hope to see a rebound once post-pandemic data is reported: 

Image credit: HRSA’s National Survey of Children’s Health, 2023

Nevada data mirror national trends. State reports estimate tens of thousands of youth experienced at least one major depressive episode in recent years, while state crisis systems have recorded sustained demand for pediatric mental-health crisis services.

For instance, Nevada’s Rural Children’s Mental Health Consortium (RCMHC) 2023 Status Report states:

“About 38,000 Nevada youth (16.02%) were reported to have experienced at least one major depressive episode in 2021, and approximately 32,000 youth (13.8%) experienced severe major depression within the last year.” 

The same report also notes the difficulty depressed adolescents have getting the help they need: “Prior to the COVID-19 pandemic, youth needing mental health services in Nevada struggled to obtain assistance with only about 40% receiving the help they need.”

These national and local/state patterns underscore the need for proactive screening and referral systems in primary care.

Who is most at risk for depression? 

Individuals within certain population and demographic groups are more likely than others to experience depression/MDD and related mental health problems. For instance:

• females are higher risk than males; 
• LGBTQ+ are higher risk than heterosexuals; 
• 9th graders are higher risk than 12th graders; 
• Native Americans are at higher risk than Asians. 

To provide a more detailed analysis of these demographic risk discrepancies, we include Table 2 from the 2023 YRBS analysis:     

Screening: who, when, and with what tool?

The U.S. Preventive Services Task Force’s (USPSTF) Depression & Suicide Risk in Children and Adolescents summary recommends implementing routine screening for depression / major depressive disorder (MDD) in adolescents aged 12–18 in settings that can ensure accurate diagnosis, treatment, and follow-up. 

For children ≤11, the evidence of benefits for proactively screening for MDD is currently insufficient. Instead, continue heightened clinician surveillance and family/caregiver screening if possible.

What are the preferred screening tools for depression in child and adolescent populations? 

Ages 12+ - 

• The PHQ-9 modified for teens provided by AACAP or the PHQ-A (with adolescent wording) provided by NIH are commonly used, nearly identical, validated screening tools that are easy to implement in primary care workflows. 
• The CES-DC (Center for Epidemiological Studies Depression Scale for Children) is another validated tool, though it is less commonly utilized than the PHQ.    

Ages ≤11 - In the event that a PCP determines screening is necessary for youth ≤11, we recommend either of the following depression screening tools: 

• CES-DC (Center for Epidemiological Studies Depression Scale for Children) designed for children ages 7-17;
• RCADS-Child (Revised Child Anxiety and Depression Scale) designed for children ages 8-18. 

(*Other depression screening tools include the Children’s Depression Inventory (CDI) and Beck’s Depression Inventory (BDI). The CDI is not free and the BDI is a free, longer screen, so they are less commonly used than the above recommendations.) 

Regardless of the depression screening tool you choose to utilize in your practice, you should establish a protocol for positive screens, as detailed in the next section. 

Immediate safety: what to do if a patient screens positive

The NV PAL Resource Library provides guides to help Nevada clinicians understand, diagnose, treat, and attain expert clinical support (through our PAL line) across a wide range of common mental health conditions, including depression. 

In our Depression Guidelines for PCPs document, we detail what you should do next, depending on a patient’s depression screening score:

Source: NV PAL's Depression Screening Guide

If screening raises concern for self-harm or suicidal ideation, perform a brief suicide risk assessment immediately; do not rely solely on screening scores. Use an evidence-based safety planning intervention (example: Stanley-Brown Safety Plan) and document access to lethal means. Involve caregivers per confidentiality and safety rules. 

For any current serious risk or inability to ensure safety, arrange Emergency Department transfer or urgent behavioral health evaluation. Again, NV PAL practitioners are here to support you via our pediatric access line if you need clinical support or assistance. 

Finally, make 988 (national Suicide & Crisis Lifeline) a visible, standard resource in the clinic and consider warm handoffs to local crisis teams if necessary.    

Additional Resource: Suicide Prevention Resource Center’s Safety Planning Guide

Treatment basics in primary care

For moderate to severe adolescent MDD, guidelines support combined psychotherapy and medication when indicated. Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT) have the strongest evidence in adolescents. 

As we detail in the NV PAL Depression Guidelines for PCPs, among medications, fluoxetine is the SSRI with the most robust pediatric evidence for ages 8+ and is commonly recommended as first-line pharmacotherapy. Lexapro (generic name: escitalopram) is another option for ages 12+ with pediatric approval. Both Rx should be prescribed with close follow-up and discussion of benefits/risks, including monitoring for treatment-emergent suicidality. 

Collaborative care models (integrated behavioral health with care management) improve depression outcomes in pediatric primary care and are worth implementing where possible. NV PAL can work with you to ensure your patients receive optimal care tailored to their specific needs while also connecting them/their families to additional resources within the local community. 

Clinical checklist

Here’s a quick wrapup checklist you can use to ensure you and/or your clinic are supporting youth with MDD in your care:  

• Implement routine screening for ages 12–18 (age-appropriate PHQs) at annuals, sports physicals, and when clinicians/caregivers express concern.
• Have a defined positive-screen pathway: brief suicide risk assessment → safety plan → expedited access to psychotherapy/psychiatry or ED if acute risk.
• Use brief evidence-based psychotherapies (refer or provide CBT/IPT) and consider fluoxetine when medication indicated; maintain 1–2 week contact early after initiation. 
• Integrate behavioral health, telepsychiatry consults, or warm-handoffs with local community mental-health teams to improve access. 
• Make sure you’re registered with NV PAL. Our services are free and our team is here to support you!  

Additional Nevada-specific resources & referral pathways

988 Suicide & Crisis Lifeline — text/call 988 for 24/7 crisis support; emphasize this to families as a safety backup. 

Website: https://www.dpbh.nv.gov/programs/crisisresponsesystemhome/

Crisis Support Services of Nevada and NAMI Southern Nevada — local crisis contacts, peer support groups, and family resources for ongoing support and linkage to outpatient care. 

Websites: https://cssnv.org/ and https://namisouthernnevada.org/ 

Let’s work together to improve early detection and outcomes for youth suffering from depression in Nevada!