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Editorials for Clinical Practice

CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.


Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.

Barbara Howard, MD

Scoring below the cut but still depressed: What to do?

Depression is one of the most common mental health conditions in childhood, especially during socially turbulent adolescence when the brain is rapidly changing and parent-child relationships are strained by the teen’s striving for independence and identity. Often parents of teens call me worrying about possible depression, but in the next breath say “but maybe it is just puberty.” Because suicide is one of the most common causes of death among teens and is often associated with depression, we pediatricians have the scary job of sorting out symptoms and making a plan.

The Guidelines for Adolescent Depression in Primary Care (GLAD-PC)1,2 were revised in 2018 to help. This expert consensus document contains specific and practical guidance for all levels of depression. But for mild depression, GLAD-PC now advises pediatricians in Recommendation II to go beyond “watchful waiting.” It states, “After initial diagnosis, in cases of mild depression, clinicians should consider a period of active support and monitoring before starting evidence-based treatment.”

Although a little vague, mild depression is diagnosed when there are “closer to 5” significant symptoms of depression, with “distressing but manageable” severity and only “mildly impaired” functioning. The most commonly used self-report adolescent depression screen, the Patient Health Questionnaire–Modified–9 (PHQ-9), has a recommended cut score of greater than 10, but 5-9 is considered mild depression symptoms. A clinical interview also is always required.

So what is this “active support” being recommended? After making an assessment of symptoms, severity, and impact – and ruling out significant suicide risk – the task is rather familiar to us from other medical conditions. We need to talk clearly and empathetically with the teen (and parents with consent) about depression and its neurological etiology, ask about contributing stress and genetic factors, and describe the typical course with optimism. This discussion is critical to pushing guilt or blame aside to rally family support. Substance use – (including alcohol) both a cause and attempted coping strategy for depression – must be addressed because it adds to risk for suicide or crashes and because it interacts with medicines.

Perhaps the biggest difference between active support for depression versus that for other conditions is that teens are likely reluctant, hopeless, and/or lacking energy to participate in the plan. The plan, therefore, needs to be approached in smaller steps and build on prior teen strengths, goals, or talents to motivate them and create reward to counteract general lethargy. You may know this teen used to play basketball, or sing at church, or love playing with a baby sister – all activities to try to reawaken. Parents can help recall these and are key to setting up opportunities.

GLAD-PC provides a “Self-Care Success!” worksheet of categories for goal setting for active support. These goals include:

  • Stay physically active. Specified days/month, minutes/session, and dates and times.

  • Engage spirituality and fun activities. Specify times/week, when, and with whom).

  • Eat balanced meals. Specify number/day and names of foods.

  • Spend time with people who can support you. Specify number/month, minutes/time, with whom, and doing what.

  • Spend time relaxing. Specify days/week, minutes/time, and doing what.

  • Determine small goals and simple steps. Establish these for a specified problem.


Exercise has a moderate effect size of 0.56 on depression, comparable to medications for mild to moderate depression and a useful adjunct to medications. The national Office of Disease Prevention and Health Promotion recommends that 6- to 17-year-olds get 60 minutes/day of moderate exercise or undertake vigorous “out of breath” exercise three times a week to maintain health. A meta-analysis of studies of yoga for people with depressive symptoms (not necessarily diagnosed depression) found reduced symptoms in 14 of 23 studies.



Advising fun has to include acknowledgment that a depressed teen is not motivated to do formerly fun things and may not get as much/any pleasure from it. You need to explain that “doing precedes feeling.” While what is fun is personal, new findings indicate that 2 hours/week “in nature” lowers stress, boosts mental health, and increases sense of well-being.



The MIND diet (Mediterranean-type diet high in leafy vegetables and berries but low in red meat) has evidence for lower odds of depression and psychological distress. Fatty acid supplements, specifically eicosapentaenoic acid at greater than 800 mg/day (930 mg), is better than placebo (P less than .001) for reducing mild depression within as little as 4 weeks. Natural S-Adenosyl-L-methionine (SAMe) has many studies showing benefit, according to National Center for Complementary and Alternative Medicine, a government-run website. NCCAM notes that St. John’s Wort has evidence for effectiveness equal to prescribed antidepressants for mild depression but with dangerous potential side effects, such as worsening of psychotic symptoms in bipolar disorder or schizophrenia, plus potentially life threatening drug interactions. While safe, valerian and probiotics have no evidence for reducing depression.

Social Support

Family is usually the most important support for depressed teens even though they may be pushing family away, may refuse to come on outings, or may even refuse to come out of the bedroom. We should encourage parents and siblings to “hang out,” sitting quietly, available to listen rather than probing, cajoling, or nagging as they may have been doing. Parents also provide support by assuring adherence to visits, goals, and medications. Peer support helps a teen feel less alone and may increase social skills, but it can be difficult to sustain because friends may find depression threatening or give up when the teen avoids them and refuses activities. The National Association for Mental Illness has an online support group (, as well as many excellent family resources. Sometimes medical efforts to be nonsectarian result in failure to recognize and remind teens and families of the value of religion, which is free and universally available, as a source of social support.


An evaluation of 15 studies concluded that relaxation techniques reduced depressive symptoms better than no treatment but not as much cognitive-behavior therapy (CBT). Yoga is another source of relaxation training. Mindfulness includes relaxation and specifies working to stay nonjudgmental about thoughts passing through one’s mind, recognizing and “arguing” with negative thinking, which is also part of CBT. Guided relaxation with a person, audiotape, or app (Calm or Headspace, among others) may be better for depressed teens because it inserts a voice to guide thoughts, which could potentially fend off ruminating on sad things.

Setting goals to address problems

In mild depression, compared with more endogenous moderate to severe major depressive disorder, a specific life stressor or relationship issue may be the precipitant. Identifying such factors (never forgetting possible trauma or abuse, which are harder to reveal), empathizing with the pain, and addressing them such as using Problem Solving Treatment for Primary Care (PST-PC) are within primary care skills. PST-PC involves four to six 30-minute sessions over 6-10 weeks during which you can provide perspective, help your patient set realistic goals and solutions to try out for situations that can be changed or coping strategies for emotion-focused unchangeable issues, iteratively check on progress via calls or televisits (the monitoring component), and renew problem-solving efforts as needed.

If mild depression fails to improve over several months or worsens, GLAD-PC describes evidence-based treatments. Even if it remits, your active support and monitoring should continue because depression tends to recur. You may not realize how valuable these seemingly simple active supports are to keeping mild depression in your teen patients at bay.

Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS ( She reported no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at


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