Supportive interventions
For all adolescents with depression, supportive interventions are helpful, and for those with mild symptoms, they are often adequate treatment. This begins with education for your patient and their parents about depression. It is an illness, not a problem of character or discipline. Advise your patients that adequate, restful sleep every night is critical to recovery. Regular exercise (daily is best, but at least three times weekly for 30 minutes) is often effective in mild to moderate depression. Patience and compassion for feelings of sadness, irritability, or disinterest are important at home, and maintaining connections with those people who offer support (friends, coaches, parents, etc.) is essential. They should also be told that “depression lies.” Feelings of guilt and self-reproach are a normal part of the illness, not facts. Organizations such as the National Alliance on Mental Illness (NAMI) and the American Academy of Child and Adolescent Psychiatry (AACAP) offer written materials through their websites that are very helpful educational resources. Connect them with sources of counseling support (through school, for example). For those with mild, brief, and uncomplicated depression, supportive interventions alone should offer relief within 4-6 weeks. It is hard to predict the trajectory of depression, so follow-up visits are relevant to determine if they are improving or worsening.
Psychotherapy
For your patients with moderate depression, or with hopelessness or suicidality, a referral for evidence-based psychotherapy is indicated. Both cognitive behavioral therapy and interpersonal therapy have demonstrated efficacy in treating depression in adolescents. If there is a history of trauma or high family conflict, supportive psychotherapy that will enhance communication skills within the family is very important to recovery. Identify various sources for high-quality psychotherapy services (individual, family, and group) in your community. While this may sound easier said than done, online services such as Psychology Today’s therapist locator can help. If your local university has a graduate program in social work or psychology, connect with them as they may have easier access to high-quality services through their training programs. If there is a group practice of therapists in your community, invite them to meet with your team to learn about whether they use evidence-based therapies and can support families as well as individual youth.
Pharmacologic options
For those adolescents with moderate to severe depression, psychotherapy alone is usually inadequate. Indeed, they may be so impaired that they simply cannot meaningfully engage in the work of psychotherapy. These patients require psychopharmacologic treatment first. First-line treatment is with selective serotonin reuptake inhibitors (SSRIs) (both fluoxetine and escitalopram are approved for use in adolescent depression). While many pediatricians remain reluctant about initiating SSRI treatment of depression since the Food and Drug Administration’s 2004 boxed warning was issued, the risks of untreated severe depression are more marked than are the risks of SSRI treatment. As prescription rates dipped in the following decade, rates of suicide attempts in adolescents with severe depression climbed. Subsequent research on the nature of the risk of “increased suicidality” indicated it is substantially lower than originally thought.
The AAP’s Guidelines for Adolescent Depression in Primary Care offer reassuring guidance: They recommend that pediatricians initiate treatment at a very low dose of SSRI (5 mg of fluoxetine, 12.5 mg of sertraline, or 5 mg of escitalopram) and aim to get to a therapeutic dose within 4 weeks.5 Educate the patient and parent about likely side effects (gastrointestinal upset, sleep disruption, akathisia or restlessness, and activation), which indicate the dose should be held steady until the side effects subside. Patients should be seen weekly until they get to a therapeutic dose, then biweekly to monitor for response. At these regular check-ins, the PHQ9A can follow symptom severity. You should monitor changes in function and for any change in suicidal thoughts. If your patient does not respond with at least energy improvement within 4 weeks, you should cross-taper to a different SSRI.