Most depressed teenagers are never seen by a psychiatrist. They are seen, if at all, by a pediatrician or family doctor, and for a long time those doctors had no guidance written for their setting. The Guidelines for Adolescent Depression in Primary Care, GLAD-PC, filled that gap. First published in 2007 by a US–Canadian expert group and endorsed by the American Academy of Pediatrics, they were updated in 2018 in the journal Pediatrics in two parts: Part I on identification, assessment and initial management (Zuckerbrot and colleagues) and Part II on treatment and ongoing management (Cheung and colleagues). They remain the reference for depression care in primary care.
Key points
- GLAD-PC provides primary care guidelines for adolescent depression, first published in 2007 and updated in 2018.
- About four in ten US high school students reported persistent sadness or hopelessness in the past year (CDC 2023).
- GLAD-PC recommends annual depression screening for adolescents aged 12 and over with validated questionnaires.
- The PHQ-A is the most common screening tool and scores around 10–11 need closer evaluation.
- Positive screens require diagnostic interviews alone and with parents, assessing symptoms, functioning, safety, and medical causes.
Why primary care matters
Depressive symptoms are common among US teenagers. In the CDC’s 2023 Youth Risk Behavior Survey, about four in ten high school students reported persistent feelings of sadness or hopelessness during the past year. In 2021 the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association declared a national emergency in child and adolescent mental health. With too few child psychiatrists in many regions, the pediatric office is often the only realistic place where depression is noticed early.
How depression looks in teenagers
Adolescent depression often looks different from the adult picture of persistent sadness. Warning signs include:
- Irritability, anger and conflict at home instead of obvious sadness
- A drop in grades or loss of interest in school
- Pulling away from friends, sports and hobbies
- Sleeping far more or far less than usual
- Frequent headaches, stomachaches or fatigue without a clear medical cause
- Changes in appetite or weight, hopeless comments, or talk about death
Symptoms that last most of the day, nearly every day for at least two weeks, and interfere with daily life suggest major depression rather than a passing low mood.
Screening
GLAD-PC recommends that adolescents aged 12 and over be screened for depression once a year with a validated questionnaire, and that young people with risk factors (family history, chronic illness, substance use, trauma, bullying, a previous episode) be watched more closely. The US Preventive Services Task Force reached a similar conclusion in 2022, recommending depression screening for adolescents aged 12 to 18.
The most common tool is the PHQ-9 Modified for Teens (PHQ-A), a one-page questionnaire. Scores of about 10 to 11 or higher call for a closer clinical look. The item on thoughts of death or self-harm is always followed up the same day, whatever the total score, and every practice needs a plan for what happens when a screen is positive.
Assessment
A positive screen leads to a diagnostic interview with the adolescent alone and with the parents, covering symptoms, duration, functioning at school and home, safety, and other conditions such as anxiety, ADHD, eating disorders or substance use. The clinician also looks for medical causes such as thyroid problems or anemia. GLAD-PC distinguishes mild, moderate and severe depression because the treatment differs.
Treatment by severity
| Severity | First-line approach under GLAD-PC |
|---|---|
| Mild | Active support and monitoring for 6 to 8 weeks: education for teen and family, regular check-ins, sleep, exercise and school support; referral for therapy if symptoms persist |
| Moderate | Evidence-based psychotherapy (cognitive behavioral therapy or interpersonal therapy) and/or an SSRI; closer follow-up and a safety plan |
| Severe, or high suicide risk | Prompt involvement of mental health specialists, immediate safety planning; combination of therapy and medication is common |
For mild depression, many episodes resolve with support and monitoring alone. For moderate to severe depression, primary care doctors can start treatment themselves, ideally in partnership with a mental health professional.
Medication and monitoring
- Fluoxetine is FDA-approved for depression from age 8 and is the best-supported choice. Escitalopram is approved from age 12.
- Since 2004, antidepressants carry an FDA boxed warning about a small increase in suicidal thoughts and behavior in children, adolescents and young adults. The risk is real but small, and untreated depression carries risks of its own.
- Doctors start at a low dose, increase slowly, and schedule contact within the first weeks: in person, by phone or by portal.
- Families watch for worsening mood, agitation, new suicidal thoughts or unusual behavior and report them right away.
- Progress is reassessed with the same questionnaire. After recovery, treatment usually continues for 6 to 12 months to prevent relapse.
Safety planning
Every adolescent with depression needs a written safety plan, worked out together with the teen and the family:
- Warning signs that a crisis may be building.
- Coping steps the teen can take alone, such as music, a walk or calling a friend.
- People and places that can help, with phone numbers.
- Professional contacts, including the 988 Suicide and Crisis Lifeline (call or text 988).
- Making the home safer: firearms stored locked, unloaded and separate from ammunition, or kept out of the home; medications, including over-the-counter pain relievers, locked away.
Restricting access to lethal means is one of the most effective suicide prevention steps a family can take.
When to refer
Severe depression, psychosis, bipolar features, substance dependence, active suicidal planning or failure to respond after two adequate trials call for referral to child and adolescent mental health services, with the primary care doctor continuing to coordinate. The 2018 update added guidance on collaborative care models in which a mental health clinician works within the practice, and it strengthened the safety-planning section.
What parents can do
- Take changes in mood and behavior seriously and ask directly how the teen is feeling. Asking about suicidal thoughts does not plant the idea.
- Schedule a visit with the pediatrician or family doctor and share observations.
- Support regular sleep, meals, physical activity and contact with friends.
- Talk with the school about temporary adjustments if grades are slipping.
Frequently Asked Questions
Can a pediatrician treat depression?
Yes. GLAD-PC was written so that primary care clinicians can screen, diagnose and treat mild to moderate depression, and refer when needed.
Are antidepressants safe for teenagers?
Fluoxetine and escitalopram are FDA-approved for adolescent depression. They carry a boxed warning, so close monitoring, especially in the first weeks, is part of safe treatment.
How long does treatment last?
Mild depression is monitored for 6 to 8 weeks. When medication helps, it is usually continued for 6 to 12 months after symptoms improve.
Where can we get help right now?
Call or text 988 at any time. In immediate danger, call 911.
This site is an independent reference on children’s mental health; the full guidelines are published in the journal Pediatrics and on the American Academy of Pediatrics website.
