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An adolescent girl presented to the emergency room with a massively distended abdomen and pain. The symptoms had progressively worsened over a period of 2 weeks causing significant discomfort and 2 episodes of nonbilious vomiting since that morning. She had a history of habitual constipation, occasionally using laxatives and enemas, with her last bowel movement 10 days ago. On examination, the patient was hemodynamically stable, with a tense, distended, and firm abdomen. She was wearing a diaper with a small amount of fecal soiling, and hard impacted feces were found on digital rectal examination. She was referred with computed tomography of the abdomen suspecting intestinal obstruction (Figure 1). In the recent past, a teenage boy presented similarly, with hugely dilated bowel loops and air fluid levels on erect X-ray abdomen. Both these children underwent urgent manual evacuation under anesthesia. In addition to pharmacological treatment with osmotic laxatives1 and rectal irrigations, both children were diagnosed with depressive disorder for which psychological counseling was provided for low mood, mood swings, and poor scholastic performance with one of them being initiated on medication. The gut-brain axis has been implicated in the association of constipation and depression, but it is uncertain whether depression is the cause or effect of constipation. A large population-based cohort study found that adults with constipation were 2.28 times more likely to develop depression over a 12-year follow-up compared with those without constipation and the risk remained significantly higher even after adjusting for confounding factors.2 A similar strong association has also been found in other population-based studies.3 Adolescents are particularly vulnerable to psychological maladjustment4 with habitual constipation, making it important for clinicians to screen and evaluate depression during treatment. This is particularly relevant in older children who present with severe constipation and fecal impaction.