Choose an antidepressant, monitor with care
Studies have shown that up to 42% of family physicians in the United States had recently prescribed selective serotonin reuptake inhibitors (SSRIs) for more than 1 adolescent under the age of 18.17 When the diagnosis of MDD without comorbid conditions is clear and the patient and family are amenable, you may want to prescribe an SSRI.7,8
If you do, warn the patient and family that antidepressants can sometimes have adverse effects, including a switch from depressive to manic symptoms, signs of behavioral activation including agitation, hostility or restlessness, and suicidal ideation or behavior. If the patient can tolerate the medication without significant adverse effects, you need to prescribe the effective dose for at least 6 to 8 weeks to ensure an adequate trial.7
TABLE 3 provides some guidance for prescribing antidepressants for adolescents with depression.7 Among the antidepressants, only fluoxetine has been approved by the FDA for children and adolescents with depression. Fluoxetine is also the SSRI with the strongest evidence for efficacy in the adolescent population, as demonstrated in 4 RCTs.18 Two studies involving fluoxetine for depression have also shown efficacy in children as young as age 7 (range, 7-12 years).19
Effective dosages for antidepressants are lower for adolescents than for adults. Initiate medications at a low dose and increase in recommended increments every 2 weeks if no significant adverse effects emerge. With the exception of fluoxetine, SSRI medications must be discontinued slowly to minimize the risk of discontinuation effects.
Once treatment begins, you or a member of your staff will need to stay in touch with the patient and family to review their continued adherence to the treatment plan. An FDA black-box warning recommends observing for “clinical worsening, suicidality, and unusual changes in behavior” during initial visits or “at times of dose changes, either increases or decreases.” Develop a regular, frequent monitoring schedule with input from the teen and her (or his) parents to ensure compliance.7,20
Make sure follow-up appointments are not missed, using flags in patient records or in the clinic schedule. The duration of treatment for teens with depression is yet to be determined through clinical trials. Most guidelines suggest drug therapy be continued at the same dosage for 6 to 12 months after symptoms resolve. Guidelines for the treatment of adolescent depression can be found at www.gladpc.org.
Keeping teenagers on an antidepressant regimen can be challenging, given the side effects, the amount of time it takes before they experience an improvement, and the lengthy duration of treatment. Families that know what to expect and are getting continuing support from you and others are most likely to stay with treatment for the duration.
TABLE 3
A guide to prescribing antidepressants for adolescents
| MEDICATION | STARTING DOSE | EFFECTIVE DOSE | MAXIMUM DOSE | NOT TO BE USED WITH | COMMON ADVERSE EFFECTS |
|---|---|---|---|---|---|
| Citalopram | 10 mg/d | 20 mg | 60 mg | MAOIs | Headache, GI upset, insomnia |
| Fluoxetine | 10 mg/d | 20 mg | 60 mg | MAOIs | Headache, GI upset, insomnia, agitation, anxiety |
| Fluvoxamine | 25-50 mg/d | 150 mg | 300 mg | MAOIs and pimozide | Headache, GI upset, drowsiness |
| Paroxetine | 10 mg/d | 20 mg | 60 mg | MAOIs | Headache, GI upset, insomnia |
| Sertraline | 25 mg/d | 100 mg | 200 mg | MAOIs | Headache, GI upset, insomnia |
| Escitalopram | 5 mg/d | 10-20 mg | 20 mg | MAOIs | Headache, GI upset, insomnia |
| MAOI, monoamine oxidase inhibitor. | |||||
| Source: This table has been adapted by Amy Cheung, MD, from her contributions to the forthcoming book tentatively entitled, Assessment and Treatment of Pediatric Depression: State of the Science; Best Practices (Editors: Peter S. Jensen, MD, Amy Cheung, MD, Ruth Stein, MD, and Rachel A. Zuckerbrot, MD), to be published by Civic Research Institute, Inc. All rights reserved. | |||||
What about Jane?
As the family’s physician, your initial management began with you educating Jane and her parents about mild depressive disorder and its likely course. You set up a series of weekly visits to monitor her symptoms and provide active support. You helped Jane find a peer support group and encouraged her to get back into gymnastics. You taught Jane and her family about the importance of keeping her safe while she is depressed, and they were cooperative about safety-proofing their home and setting up a plan to handle emergencies.
Should you screen every teen? Guidelines have changed
The US Preventive Services Task Force now recommends screening all adolescents (12-18 years of age) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive behavioral therapy or interpersonal therapy), and follow-up. Previously, the Task Force concluded that the evidence was insufficient to recommend for or against the practice. For more on the Task Force’s recommendations, go to www.ahrq.gov/clinic/uspstf09/depression/chdeprrs.htm.