Irritability, angry outbursts, eye-rolling—all are hallmarks of adolescence. But at what point do negative emotional behaviors go beyond teenage snark to signal clinical depression?

The question isn’t trivial, says psychiatrist Leslie Miller, who has made answering it a focus of her practice and clinical study. The need to catch depression early in a demographic known for high suicide risk drives her work. If clinicians could pinpoint when subtle changes in behavior raise the risk of mood disorders, she says, what a boon that would be.

For now, in intake interviews, Miller notes any possible predictors, their frequency and when, or if, there’s been descent into depression. Miller directs MAP, the established Johns Hopkins Mood Disorders in Adolescents and Young Adults Program. Its research and successes with patients at such vulnerable ages—most between 12 and 22—first depend on parents referring their children.

Yet adolescence itself slows referrals.

Teenage paths to depression often don’t mirror those of adults. Rather than sadness, for example, irritability and angry outbursts may dominate. Also, for some adolescents, dark moods appear less intense. Says Miller: “A parent will say to me, ‘My daughter often smiles. Or laughs! How could she be depressed?’ Teens, however, can be very good at hiding what’s going on.”

Often, by the time patients arrive, their negative emotional responses have escalated to depression or disruptive mood dysregulation disorder, another mood illness. In the latter, chronically irritable youths erupt in anger truly out of proportion to a situation.

Part of the challenge, then, Miller explains, is getting everyone on the same page. In the first family interview, she asks young patients, “Have you ever had thoughts about not wanting to live?” Hearing yes stuns parents. Yet frankness, she says, can be crucial in helping them appreciate where things stand.

 Assessing patients with skill, of course, guides what treatment paths to choose. And in querying teens about mood, sleep habits, social withdrawal or any form of self-harm, Miller also builds their trust. 

It’s a clinically diverse MAP team that pools both observations and insights to design each patient’s plan. Most combine medication and research-based psychosocial approaches, such as interpersonal psychotherapy. Role-playing, for example, and helping teens recognize wayward ways of communicating and problem-solving readies them to tap the power of positive encounters with others to improve mood. Dialectical behavioral therapy and cognitive behavioral therapy are also at hand.  

 Miller also believes—and evidence shows—“that including families from the start is essential to successful treatment. You can involve families and still honor a patient’s autonomy and independence.”