9.3 Anxiety, Depression & Suicide Risk

Anxiety, depression, and suicide risk are the other half of clinical category #1. PNCB writes them as school-avoidant stomachaches, a teenager who stopped soccer, and a positive ASQ at a well visit. Domain II is assessment with validated tools. Domain III is primary-care management: CBT, selected SSRIs, tight follow-up, and knowing when the office is no longer a safe disposition. Promotion counseling (media, sleep, lifestyle) lived in Domain I.E. This section is diagnosis and treatment.

Anxiety disorders you will actually see in clinic

Generalized anxiety is excessive, hard-to-control worry across domains (school, family, world events) with restlessness, fatigue, poor concentration, irritability, muscle tension, or sleep disturbance. Separation anxiety is developmentally normal in toddlers; it becomes a disorder when fear of separating from attachment figures is persistent and impairing in a school-age child (school refusal, shadowing, catastrophic "what if you die" thoughts). Social anxiety is fear of scrutiny and humiliation, not ordinary shyness — the child avoids raising a hand, eating in the cafeteria, or sports tryouts. OCD-spectrum presentations include time-consuming obsessions and compulsions (washing, checking, repeating, need for symmetry). OCD is still primary-care recognizable; evidence-based treatment is CBT with exposure and response prevention, often plus an SSRI, and referral is appropriate when rituals run the household.

The SCARED (Screen for Child Anxiety Related Disorders) is a common child-and-parent tool in school-age children. GAD-7 is a practical adolescent screen. Neither tool is a diagnosis. Interview function: sleep, somatic pattern, avoidance, and whether the child can still attend school. Avoidance is the behavior that grows anxiety; a graded return-to-school plan beats waiting until the child "feels 100% ready."

Clinic vignette. A 7-year-old has missed 12 Mondays with epigastric pain after a family move six weeks ago. Exam is benign, growth is fine, PHQ-A is negative, SCARED is high on separation items. This is not an automatic SSRI and not a GI referral as the only act. Name anxiety, start CBT/caregiver coaching, and keep the child in a return-to-school plan.

Depression: PHQ-A, anhedonia, sleep, school

AAP, USPSTF, and GLAD-PC support routine adolescent depression screening. The PHQ-A (PHQ-9 modified for adolescents) is the usual instrument. A number is not the whole visit. Ask anhedonia (stopped activities that used to matter), sleep (too little or too much), appetite, energy, guilt, concentration, and school drop (grades, attendance, sport). Ask caregivers for collateral; many adolescents minimize or, conversely, score high during an acute fight.

Mild depression: GLAD-PC supports active support and monitoring for about 6–8 weeks and CBT as first-line treatment. Moderate to severe depression, psychosis, bipolar clues, or failed supportive care: psychotherapy and/or medication, with a lower threshold to collaborate with psychiatry. You still own safety screening at every contact.

SSRIs: which ones are FDA-approved, and the boxed warning

Know the pediatric labels rather than inventing a dosing table for every milligram:

• Fluoxetine is FDA-approved for childhood and adolescent major depression (and for OCD at younger ages).
• Escitalopram is FDA-approved for adolescent depression.
• Other SSRIs are used, but they are not the first names to reach for when the item asks what is FDA-approved for pediatric depression. Paroxetine is not the pediatric-depression first-line story.

Start low, give the family a realistic onset (often 4–6 weeks for full effect), and do not open at adult doses in a small or medication-naive adolescent. All antidepressants carry a boxed warning for suicidality in children, adolescents, and young adults. That warning is counseling plus monitoring, not a reason to withhold indicated treatment for moderate-severe depression.

Follow-up after an SSRI start is part of the prescription. AAP/GLAD-PC expect contact within the first weeks — commonly weekly for the first month, then every other week, then monthly, aligned with FDA monitoring language. "Start fluoxetine and return in three months" is the trap. Ask mood, activation, insomnia, akathisia, and suicidal thoughts at those contacts. Provide a way to reach the office between visits.

Clinic vignette. A 14-year-old has a PHQ-A of 16, anhedonia, falling grades, no active plan or intent, and wants medication while starting CBT. Fluoxetine (or escitalopram, given adolescent age) with boxed-warning counseling and a visit or call in the first week is guideline-consistent. A tricyclic as first-line, paroxetine as the default, or a three-month silent gap is not.

Suicide: ASQ, safety planning, means, emergency

Use a structured screen. The NIMH Ask Suicide-Screening Questions (ASQ) is built for medical settings: recent wish to be dead, feeling that the family would be better off, thoughts of killing oneself, and prior attempt, plus an acuity item if any answer is yes. A positive screen is not automatically an admission, but it is never ignored.

Safety planning is a written, brief plan: warning signs, internal coping, social contacts, professionals (including 988), means restriction, and reasons for living. Means restriction is a clinical intervention: firearms locked and ammunition separate (preferably stored out of the home during crisis), medications locked, ligatures and keys addressed with the caregiver. Ask firearms out loud. Do not skip the gun question because the well visit felt "routine."

Send to emergency evaluation when there is a plan, intent, agitation or psychosis, intoxication, inadequate adult supervision, or inability to create a credible safety plan. A 16-year-old who describes using a household firearm tonight and will not engage in planning does not go home with a worksheet.

Do not promise secrecy. Suicidal thoughts, plans, and intent break adolescent confidentiality. Tell the youth you will keep private what you can, and that safety information will be shared with a caregiver so they can be protected. Surprise betrayal after a promise of silence destroys the alliance and is the wrong exam answer.

Trauma/PTSD and adjustment disorder on the differential

Not every new worry after a move is GAD, and not every sad month is major depression.

• Adjustment disorder — emotional or behavioral symptoms within 3 months of an identifiable stressor, out of proportion or impairing, not meeting another full disorder, and not persisting more than 6 months after the stressor ends. Support, CBT skills, and watchful follow-up often suffice; jumping to an SSRI the week of a relocation is not automatic.
• PTSD — exposure to actual or threatened death, serious injury, or sexual violence, plus intrusion (nightmares, flashbacks), avoidance, negative mood/cognitions, and hyperarousal lasting more than 1 month. Trauma-focused psychotherapy is first-line; do not treat hypervigilance as ADHD or "just anxiety" without the trauma history.
• Grief after a death can look like depression; persistent, pervasive anhedonia and worthlessness still need a depression assessment and a safety screen.

Always screen suicide risk when you diagnose depression, PTSD, or a significant adjustment reaction. Comorbid ADHD does not get a stimulant-only plan if the acute problem is a suicide plan.

Exam traps

1. Starting an SSRI as automatic first-line for mild anxiety or mild depression when CBT and active support are indicated.
2. Choosing a non-FDA pediatric depression story (or a tricyclic) when fluoxetine/escitalopram is the labeled path.
3. No follow-up in the first weeks after an SSRI — the boxed warning is operationalized as contact, not a signature on a handout.
4. Sending home a youth with plan and intent because the PHQ-A was only moderate.
5. Promising secrecy about suicidal thoughts.
6. Missing trauma and adjustment disorder and over-diagnosing GAD or ADHD.

Tool, interview, CBT for mild, labeled SSRI with early follow-up for more, safety plan without secrecy promises. That is 9.3.