Symptoms of depression during adolescence are more similar to those seen in adult-onset depression The major symptom is a sad, unhappy or irritable mood, and/or a pervasive loss of interest and pleasure Other symptoms may include a change in appetite, change in a sleep behavior, and psychomotor retardation or agitation Also present in many depressed teenagers are loss of energy, feelings of worthlessness or excessive guilt, decreased ability to concentrate, indecisiveness, and recurrent thoughts of death or suicide Depressed teenagers can also present with somatic complaints, academic problems, promiscuity, drug or alcohol use, aggressive behavior, and stealing Many teenagers with behaviors such as these are unaware of their depression, others simply deny it In talking with these patients about their lives at home, at school, and with peers, the underlying depression usually becomes apparent A medical evaluation is needed to rule out potential medical causes, concurrent medical illness, and to assess for self-injurious/suicidal behaviors and side effects of prescribed medications See Table 126.2 The AACAP Depression Resource Center can be accessed at https://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Dep ression_Resource_Center/Depression_Resource_Center.aspx Management The major goals in the management of depression in the ED involve (i) determining suicidal risk (ii) uncovering acute precipitants, (iii) making an appropriate disposition, and (iv) creating a safety plan ED physicians should screen for the presence of suicidal ideation as well as any history of prior attempts Direct questions about suicidal thoughts are critical They are unlikely to catalyze suicide attempts and may actually provide a sense of relief for the depressed child The physician should attempt to determine possible acute precipitants to guide subsequent recommendations The duration of the depression should be determined as well as the family’s response Assessing overall adjustment at home, in school, and with peers is important, as well as looking for the strengths of child and family for use in the treatment plan Outpatient management may be considered when adequate social support is present Parental acknowledgment of the severity of and risk associated with their child’s symptoms as well as a strong commitment to participating