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Objectives/Hypothesis For most pediatric specialty clinics, mental health is not the primary presenting complaint, yet can portend unrecognized morbidity. We describe rates and risk factors of depression and suicidal ideation in adolescents seen at a pediatric specialty clinic and examine changes during COVID‐19. Study Design Retrospective database review. Methods Outpatient pediatric otolaryngology clinic encounters of patients aged 12–19 years at a tertiary academic medical center were identified from October 2018 to July 2020. Demographic characteristics, ICD‐10 primary diagnosis, Patient Health Questionnaire (PHQ)‐2 score, and PHQ‐9 score (if administered) were obtained. Multivariable regression examined risk factors for PHQ‐9 administration, PHQ‐9 scores ≥10, and suicidal ideation. Patient characteristics and PHQ scores were compared before and after March 23, 2020 (California COVID‐19 Stay‐at‐Home order). Results Three thousand six hundred nine encounters with PHQ‐2 data were identified. Of these, 223 (6.2%) scored ≥3 and underwent PHQ‐9 assessment, of which 121 (3.4% of 3,609) scored ≥10 on the PHQ‐9 and 53 (1.5%) endorsed suicidal ideation. Factors associated with PHQ‐9 administration were female gender (odds ratio [OR] 1.58, P = .001), obesity (OR 1.48, P = .043), and neck mass/neoplasm/cancer diagnosis (OR 1.99, P = .013). Female gender was also associated with suicidality (OR 2.47, P = .008). Comparison of pre‐COVID‐19 versus during COVID‐19 showed no differences in depression or suicidality. However, subgroup analysis revealed some significant findings. Conclusions We demonstrate substantial prevalence of positive depression screening and suicidal ideation among adolescent pediatric otolaryngology clinic encounters. Depression rates were similar to pre‐COVID‐19 and during COVID‐19, yet barriers to screening during this time were substantial. Pediatric specialty providers must remain vigilant for mental health issues in their patients. Level of Evidence 3 Laryngoscope, 132:1104–1111, 2022