I recently treated a 15-year-old girl who complained of being tired all the time.  Upon further questioning, she reported feeling this way for the last few months.  She admitted to problems focusing, increased anger and irritability and difficulty sleeping at night, and reported not caring about things she used to care about, like spending time with friends and keeping her room organized and clean. 

This social situation is not unique to children and adolescents during these difficult economic times. This patient is living with her single mother. They have been renting a house that had been for sale all spring, but just sold.  This patient and her mother do not know where they are going to live, money is tight and the patient does not have any idea what high school she will be attending in the fall. 

Statistics show that 8% of 12 to 17 year olds have experienced at least one major depressive episode in the last year, and only 39% of these patients receive treatment. Depression can affect all aspects of an adolescent’s life — worry, poor sleep and lack of focus often impact grades. Irritable moods and anger interfere with relationships with family and friends. There is an increased risk of self-medication with illegal drugs, smoking and alcohol. Also, let’s not forget that suicide is the third leading cause of death among 11 to 18 year olds (Eaton, 2008). 

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Lack of awareness among primary care providers is a big problem, as only 23% of screen for mental health disorders and only 34% of patients report that a provider ever discussed their emotional health with them. Furthermore, few teens seek help or disclose thoughts of suicide or suicide attempts with others.

Asking about emotional wellbeing can be daunting.  It is particularly difficult if you practice in an area where mental health and behavioral resources are scarce, or your patient population has limited financial resources.

The financial issues related to current high unemployment rates have added another layer to the developmental and social issues every teen faces. Asking about depression and other mental health issues is at least, if not more important than reviewing physical systems. 

Even if there are not adequate mental and behavioral health services available in your area, or families don’t have the resources to pay for them, simply allowing children and adolescents the opportunity to open up in a non-judgmental environment about their worries, and acknowledging that their feelings are legitimate can help relieve some of the burden. 

Although most primary care nurse practitioners do not have training in mental health counseling, it is within our scope of practice to enlist support from the patient’s family or other trusted adults, provide treatment with medication if warranted and refer to counselors if possible.

For more ideas about improving your practice’s approach to child and adolescent mental health, please refer to the American Academy of Pediatrics Task Force on Mental Health’s “Strategies for System Change in Children’s Mental Health:  A Chapter Action Kit.”  

Julee B. Waldrop, DNP, FNP, PNP, is the Director of the MSN-DNP Program and an associate professor at the University of Central Florida. She provides health care to children at a local community health center.


  1. Eaton D et al. “Youth Risk Behavior Surveillance – United States, 2009.”  MMWR. 2010; 59 (SS05):1-142.