Pedemy All toolsTap the teen’s answers. The PHQ-A total and the ASQ result update at once, with what to do next. A positive suicide screen always comes first — never send a patient home before acting on it.
This tool scores two free screening instruments used with adolescents. The PHQ-A, the PHQ-9 modified for teens, has nine items scored 0 to 3 for the past two weeks, giving a total of 0 to 27: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–19 moderately severe and 20–27 severe. In 13- to 17-year-olds a total of 11 or more detected major depression with about 90% sensitivity and 78% specificity (Richardson, Pediatrics 2010). Any positive answer on item 9, about being better off dead or self-harm, sends you straight to the suicide-risk questions.
The NIMH Ask Suicide-Screening Questions (ASQ) are four yes-or-no questions about wishing to be dead, thinking the family would be better off, recent suicidal thoughts and past attempts. If all are no, the screen is negative. Any yes, or a refusal in a young person, means asking a fifth question: thoughts of killing yourself right now. A yes is an acute positive screen, so the patient stays under observation for a stat mental health evaluation. A no is a non-acute positive screen needing a brief suicide safety assessment.
Next steps follow the AAP-endorsed GLAD-PC guidelines (2018) and the 2022 USPSTF statement. Screen every adolescent 12 and older each year. For mild depression, give active support and monitoring for 6 to 8 weeks. For moderate or severe depression, start CBT or interpersonal therapy and/or an SSRI: fluoxetine (FDA-approved from age 8) or escitalopram (from age 12), with close follow-up because of the boxed warning. Every positive screen gets a safety plan, lethal-means counseling and the 988 Lifeline.
Totals of 5–9 are mild, 10–14 moderate, 15–19 moderately severe and 20–27 severe. A cutoff of 11 or more had about 90% sensitivity and 78% specificity for major depression in 13–17-year-olds. Always confirm with a clinical interview, and follow up any positive item 9 whatever the total.
Both mean a yes (or, in youth, a refusal) to at least one of the first four questions. Acute positive means yes to question 5, thoughts of killing yourself right now: the patient cannot leave, stays in sight and needs a stat mental health evaluation. Non-acute positive means no to question 5: do a brief suicide safety assessment before the patient leaves.
Fluoxetine is approved for depression from age 8 and escitalopram from age 12. GLAD-PC recommends evidence-based therapy and/or an SSRI for moderate or severe depression, with close monitoring for worsening, suicidality and unusual behavior, especially in the first months and after dose changes.
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