A 15-year-old boy is brought to the office by his father due to concerns about changes in his behavior. The father says, "My son just sits in his room for hours. He quit the basketball team and gets annoyed with his older brothers for no reason. He seems less motivated to do well in school and doesn't seem to care about anything. His mother is upset because he doesn't listen and has started talking back to her. He has never been defiant like this before. He won't talk to me and I am concerned that he might be using drugs." When seen alone, the patient reports that he would rather stay in his room as he does not enjoy going out, because it is "boring." He says he is not using drugs, adding, "I have never done that stuff." He reports getting tension-like headaches a few times a week for the last year but has no other physical concerns. Physical examination is normal. Which of the following is the best next step in management of this patient?

Question

A 15-year-old boy is brought to the office by his father due to concerns about changes in his behavior.  The father says, "My son just sits in his room for hours.  He quit the basketball team and gets annoyed with his older brothers for no reason.  He seems less motivated to do well in school and doesn't seem to care about anything.  His mother is upset because he doesn't listen and has started talking back to her.  He has never been defiant like this before.  He won't talk to me and I am concerned that he might be using drugs."  When seen alone, the patient reports that he would rather stay in his room as he does not enjoy going out, because it is "boring."  He says he is not using drugs, adding, "I have never done that stuff."  He reports getting tension-like headaches a few times a week for the last year but has no other physical concerns.  Physical examination is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Some irritability, withdrawal from family in favor of friends, and testing of limits are expected as adolescents discover their autonomy and self-identity. However, this patient's symptoms are impairing in both an educational and social context (eg, lack of enjoyment and engagement), suggesting more than ordinary adolescent behavior. Adolescent depression is often first encountered in the primary care setting and can be overlooked as it may present with irritability, boredom, and/or somatic symptoms, as opposed to depressed mood. In addition, children and adolescents may struggle to express their feelings or may not openly confide in parents or physicians, making the diagnosis of depression more difficult. This patient's irritability, social isolation, and lack of engagement in activities he previously enjoyed are concerning for depression. His symptoms should not be dismissed as normal behavior (Choice C); assessment for depression is warranted. Untreated depression can result in further decline in academic and social functioning and increase the risk for suicide. (Choice A) This patient has a normal neurological examination with no other symptoms concerning for intracranial pathology (eg, early-morning headaches, papilledema, nuchal rigidity, progressive severity or change in character of headaches). Brain imaging is not indicated. In contrast, depression and anxiety often present with nonspecific somatic complaints. (Choice B) Drug use can result in altered behavior. However, because this patient has denied any drug use, requesting a urine toxicology screen before engaging him in further discussion and assessing depressive symptoms would convey distrust and likely damage the physician-patient relationship. (Choice D) Family therapy can be helpful in treating family dysfunction contributing to a patient's symptoms. However, a thorough evaluation for depression should take place first as additional treatments, including pharmacotherapy or individual therapy, may be required. Educational objective: Adolescent depression can present with irritability or somatic symptoms rather than depressed mood and may be mistaken for normal adolescent behavior. Associated symptoms, such as decline in educational and social functioning, should prompt assessment for depression. References: Adolescent depression: clinical features and therapeutic strategies. (http://www.ncbi.nlm.nih.gov/pubmed/23771545) Guidelines for adolescent depression in primary care (GLAD-PC): I. Identification, assessment, and initial management. (http://www.ncbi.nlm.nih.gov/pubmed/17974723)

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