A 15-year-old boy is brought to the office by his parents due to concern about a change in his behavior. Over the past 3 months he has become more withdrawn, spending more time alone and turning down opportunities to socialize with his friends. He is frequently moody and irritable. The patient feels unmotivated at school and seems unconcerned that his grades have dropped. His parents believe that his behavior changed after he was rejected by a girl, who subsequently called him a "loser" on social media. When seen alone, the patient says, "I don't think I will ever get over this girl," who he believes was his "soul mate." He uses marijuana occasionally but does not use alcohol. Physical examination is normal apart from a 2.7-kg (6-lb) weight loss since his last visit. He says, "I feel pretty down. I would consider talking to someone or taking medication but don't want to worry my parents." Which of the following is the most appropriate step prior to initiating treatment for this patient?

Question

A 15-year-old boy is brought to the office by his parents due to concern about a change in his behavior.  Over the past 3 months he has become more withdrawn, spending more time alone and turning down opportunities to socialize with his friends.  He is frequently moody and irritable.  The patient feels unmotivated at school and seems unconcerned that his grades have dropped.  His parents believe that his behavior changed after he was rejected by a girl, who subsequently called him a "loser" on social media.  When seen alone, the patient says, "I don't think I will ever get over this girl," who he believes was his "soul mate."  He uses marijuana occasionally but does not use alcohol.  Physical examination is normal apart from a 2.7-kg (6-lb) weight loss since his last visit.  He says, "I feel pretty down.  I would consider talking to someone or taking medication but don't want to worry my parents."  Which of the following is the most appropriate step prior to initiating treatment for this patient?

Quizplus · Accepted Answer

This patient shows signs and symptoms concerning for depression (eg, social isolation, lack of motivation, irritable mood, academic decline, weight loss). Before initiating treatment, a suicide-risk assessment must be performed because it could have immediate implications for safety and for determining the appropriate treatment setting. The physician should ask specific questions in a direct and nonjudgmental manner. These include: Do you wish you were dead? Are you having thoughts about harming or killing yourself? Have you made any plans or preparations to kill yourself? Have you ever tried to kill yourself? Suicide is a leading cause of death in adolescents. The combination of depression (particularly in the setting of rejection and humiliation/cyberbullying) and impulsivity (which is characteristic of adolescence) places this patient at increased risk and should not be underestimated. Confidentiality should not be promised because it cannot be maintained if there is a concern for safety (Choice A). Depending on the assessment, this patient may require immediate psychiatric evaluation in the emergency department and/or hospitalization. (Choices B, D, and G) Although parental consent is required to prescribe medication, and it is important to respond to this patient's interest in treatment, it is premature to recommend treatment with antidepressants and/or psychotherapy prior to completing a thorough assessment. (Choice C) Although adolescents should be encouraged to involve their parents in decision-making, the priority in this case is to determine if the patient is a danger to himself. If there is any concern for the patient's safety, the parents must be informed with or without consent. (Choice F) This patient has had persistent depressive symptoms for 3 months and should not simply be reassured. A thorough evaluation for depression, including careful screening for suicidal thoughts, is necessary. Educational objective: Suicide-risk assessment in adolescents should include direct and nonjudgmental questions to determine the nature and intensity of suicidal thoughts. Confidentiality should not be promised because it cannot be maintained if the patient is at high risk for self-harm. References: Mood disorders in adolescents: diagnosis, treatment, and suicide assessment in the primary care setting. (http://www.ncbi.nlm.nih.gov/pubmed/25124208) Risk assessment and initial management of suicidal adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/24897985)

A 15-Year-Old Boy Is Brought to the Office by His