Teenage Zebras: Looking for Adolescent Depression in the Midst of Adaptive Teenage Angst


Chronic pain and functional limitations, along with these academic and social difficulties, are directly related to mental health complaints. Therefore, adolescents with rheumatic diseases are at a higher risk for developing mental illness.

One of the groups most vulnerable to poor psychosocial outcomes in rheumatic disease is teens. The symptoms of rheumatic disease almost always cause disruptions in the daily functioning of pediatric rheumatology patients; in some research, more than 90% of participants reported that their disease interfered with their normal daily living.1 With rheumatic disease, half of young people report changes in relationships and 70% report that their disease interfered substantially with extracurricular and leisure activities. Teachers and caregivers notice this toll and report an increased risk for academic difficulties, decreased social contact, and peer rejection.2 Chronic pain and functional limitations, along with these academic and social difficulties, are directly related to mental health complaints. Therefore, adolescents with rheumatic diseases are at a higher risk for developing mental illness. The prevalence rates of major depression in this population range as high as 65% and, importantly, the prevalence of suicidal ideation is more than 30%.3

Maddy Pontius, BA

Maddy Pontius, BA

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Pediatric rheumatologists have the unique opportunity to address mental health issues where emotional distress may otherwise go unrecognized. You will obviously notice that your teen patient is distressed, but it can be hard to distinguish teenage angst from a cry for help or the kind of distress that warrants intervention.4 Teens who are depressed or anxious may exhibit emotional outbursts, such as crying or temper tantrums, appear irritable, agitated, or distracted, and will report changes in appetite, sleep, or energy. Some teens will report feelings of sadness or hopelessness and worry or fear, especially about the future or their medical condition. You may hear about self-destructive behavior, such as skipping school, substance use, and self-harm. Often, depression and anxiety present with physical symptoms like stomachache, headache, dizziness, and increased heart rate, and more pain complaints. In teenagers, these symptoms are relatively common so you will attend to and evaluate 2 dimensions: duration and disruption.The DSM-V defines diagnostic categories by clinical concerns that are present every day for 2 weeks or more. Disruption occurs when distress interferes with daily activities, such as school, home, or social interactions. As a rehabilitation psychologist, I also advise physician colleagues to look for change. For example, an increase in pain severity, headaches, and stomachaches or sudden change in hygiene or mood. Where appropriate, you should also talk to parents who have the rest of the clinical picture you need to determine the severity of your patient’s complaints. Parents who were polled, report feeling the most comfortable discussing emotional health concerns with their rheumatologist because of increased trust and confidence in the therapeutic relationship.3

You can also add a mood screening to your regular intake process.5 The PHQ-9 and GAD-7 are each sensitive, specific, and designed to assess the presence and severity of depression and anxiety symptoms. On both instruments, watch for scores greater than 10 (“Thoughts that you would be better off dead, or thoughts of hurting yourself in some way” should be assessed immediately for suicide risk). In these cases, you can initiate a referral to a trusted mental health provider, and you should do that emergently in the case of emotional or behavioral problems that constitute a threat to the safety or themselves or others. Consider a less emergent, but prompt, referral in a case where you’ve noticed a significant change in your patient’s emotional and behavioral functioning or if your patient’s behavior interferes with the treatment of their condition.6 The best time to meet a local psychologist or licensed therapist is before you need them so ask to present at a local conference or invite local colleagues to present to your staff over lunch or via zoom.

You can also use web-based resources like the Anxiety and Depression Association of America or Psychology Today. Outside of doing nothing, there is no wrong way to assess and respond to mental distress. With every action, you are combatting the barriers to mental health care and psychology thanks you.


Russo, E., Trevisi, E., Zulian, F., Battaglia, M., Viel, D., Facchin, D., Chiusso, A., & Martinuzzi, A. (2012). Psychological Profile in Children and Adolescents With Severe Course Juvenile Idiopathic Arthritis. The Scientific World Journal. https://doi.org/10.1100/2012/841375

Kashikar-Zuck, S., Lynch, A., Graham, T., Swain, N., Mullen, S., & Noll, R. (2007). Social functioning and peer relationships of adolescents with juvenile fibromyalgia syndrome. Arthritis Care and Research, 57(3), 474-480. https://doi.org/10.1002/art.22615

Davis, A., Rubinstein, T., Rodriguez, M., & Knight, A. (2017). Mental health care for youth with rheumatologic diseases – bridging the gap. Pediatric Rheumatology Online Journal, 15. doi: 10.1186/s12969-017-0214-9

Serani, D. (2014). Is It Teen Angst or Depression? Retrieved from: https://www.psychologytoday.com/us/blog/two-takes-depression/201410/is-it-teen-angst-or-depression

Rubinstein, T., Dionizovik-Dimanovski, M., Kraus, R., Jones, J., Harris, J., Rodriguez, M., Tesher, M., Faust, L., Rutstein, B., Smith, C., Puplava, R. Rojas, E., Davis, A., Sule, S., Onel, K., von Scheven, E., & Knight, A. Patient and Parent Acceptability of Mental Health Screening in the Rheumatology Clinic for Youth with Systemic Lupus Erythematosus. Retrieved from: https://carragroup.org/UserFiles/file/2018%20Abstracts/2018abstract-rubinstein2.pdf

American Academy of Child & Adolescent Psychiatry. When to Seek Referral - Recommendations for Pediatricians, Family Practitioners, Psychiatrists, and Mental Health Practitioners. Retrieved from https://www.aacap.org/aacap/Member_Resources/Practice_Information/When_to_Seek_Referral_or_Consultation_with_a_CAP.aspx

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