Depression is a widespread clinical condition that affects many worldwide. Both adolescents and the elderly seem to experience depression more severely. This tends to result in a higher incidence of suicidal ideation amongst both of these groups. We present the case of a teenage patient who was being treated for major depressive disorder. She began cutting behavior and this ultimately evolved into a suicide attempt necessitating her inpatient psychiatric hospitalization. We follow her from her initial clinical encounter for her depression to her first outpatient psychiatry appointment following her discharge. The numerous social, genetic, and systemic factors that could have likely contributed to her suicide attempt are also discussed.

[1]. [2]. [3]. Major depressive disorder (MDD) was ranked as the third cause of the burden of disease worldwide in 2008 by WHO, which projected that this would rank first by 2030[1]. It is diagnosed when an individual has a persistently low or depressed mood, anhedonia, feelings of guilt or worthlessness, lack of energy, poor concentration, appetite changes, or sleep disturbances [1]. Major depressive disorder is one of the most common psychiatric disorders of childhood and adolescence [2]. Symptom severity predicts the initial mode of treatment ranging from psychotherapy to medications to combination treatment [2]. Untreated depression in children and adolescents is believed to increase the risk of substance abuse, poor academic functioning, and the risk of suicidal behaviors [2]. Suicide is a serious health problem as it is currently the third leading cause of death for teenagers between the ages of 15 and 24 years [3]. Depression has been implicated as the most significant biological and psychological risk factor for teen suicide [3].  This article will follow a teenage patient with major depressive disorder from her initial clinical encounter to her suicidal attempt landing her in an inpatient psychiatric ward.

Emma was a 14-year-old female with an insignificant medical history that presented to the clinic with her mother with complaints of anxiety in the year 2024. Her parents had just gone through a divorce and she was struggling to cope with the changes and dynamics within the household. She initially endorsed a history of present illness that was consistent with an unspecified anxiety disorder, adjustment disorder, and a major depressive disorder (Figure 1).

                                                                                                        Figure 1: Columbia Depression Scale

 Figure 1: Figure 1 showcases the Columbia Depression Scale that is used for diagnosing clinical depression in children [4].

Upon further questioning Emma stated that she felt depressed at least once a week, and that she was having difficulty sleeping. Furthermore, she stated that she was having increased anxiety which seemed to be triggered by groups of people and loud noises. She was only eating one time a day, which may have been due to her finding school food disgusting. Due to her finding school difficult, she had low grades in several classes. She proceeded to mention a family incident that she didn’t want to discuss that led to her doing even more poorly at school. On a psychiatric status exam, she was found to have a fully intact mental status without overt manifestations of psychological distress. Over the next year Emma began a downward spiral with her mental health. She had a counselor that she confided in with her secrets, who was abruptly arrested for kidnapping. She felt betrayed and that gave her both anxiety and trust issues. She also was having issues with getting along with others at her school which led to entire sport teams ridiculing her. On top of this, she had a volatile home situation with her mom with bipolar disorder who would go through rapidly cycling manic episodes which would result in significant abuse. She began to not get along as much with her siblings at home which was new for her. This meant physical altercations would occur at times. All these stresses took a significant toll on her mental health and she began to cut herself. She started off by cutting her upper extremities. On one occasion she became so frustrated that she grabbed a butcher’s knife and sliced a superficial cut across her stomach. She further gave in to her depression when she attempted to strangle herself with a leather belt. She wrapped the belt around her neck and kept it fastened until she saw stars, at which point she reconsidered her decision and removed it.  She was left with a gigantic bruise around her neck which she tried to conceal when she went back to school by wearing a hoodie. The school nurse discovered this and also bruises on her hands which were believed to be caused by punching a wall. After her mother was notified of this suicide attempt, the family agreed to have her hospitalized in an inpatient psychiatric ward. She was started on fluoxetine and a few sleep medications as needed. When her condition improved, she followed up in an outpatient psychiatric clinic where she further endorsed her depression and anxiety symptoms. She did not endorse any suicidal or homicidal ideation and her psychiatric status was fully intact on examination.

Emma had numerous sources of stress which were out of her control. She was initially presenting with major depression following her parents’ divorce and an incident that was being reviewed by DCS which she did not want to discuss. It seemed she had quite a reasonable source of distress and was forthcoming towards discussing her feelings and being treated by a medical professional. While she had established treatment by a psychiatrist, it is likely that she needed more assistance for her needs and issues at the house. It is unclear what specifically occurred during the incident she did not want to discuss, and that could potentially cause long lasting psychological distress. She was also receiving a significant amount of bullying at school which also would have added to her depression. The school administration may not have been informed of this occurring, or had not taken definitive action to correct it. Her trust issues and anxiety stemming from her counselor being arrested seem to be the normal responses to such an aberrant event, however it must be admitted that she was simply unfortunate to have experienced this. There seems to be a likelihood that if numerous sources of her depression were addressed earlier in time, it may not have led to her suicide attempt and inpatient psychiatric hospitalization.

Teenage kids experience stress from a wide array of sources. A large number of teenager’s experience depression and they are significantly at risk of becoming suicidal. Diligent efforts must be made to diagnose and treat major depression in kids.

Statement of Informed Consent:

Informed consent was obtained from both the patient and a parent.