From the Guidelines
Depression in adolescents is best treated with a combination of psychotherapy and medication when symptoms are moderate to severe, as recommended by the guidelines for adolescent depression in primary care 1.
Treatment Approach
The treatment approach should be based on the severity of symptoms. For mild depression, Cognitive Behavioral Therapy (CBT) or Interpersonal Therapy (IPT) should be the first-line treatment, with sessions typically occurring weekly for 12-16 weeks.
- CBT and IPT are effective in addressing negative thought patterns and providing adolescents with coping skills.
- These therapies can be used alone for mild depression or in combination with medication for moderate to severe depression.
Medication
For moderate to severe depression, selective serotonin reuptake inhibitors (SSRIs) are recommended, with fluoxetine (Prozac) being the preferred medication due to its established efficacy and safety profile in adolescents 1.
- The starting dose of fluoxetine is typically 10mg daily for one week, then increased to 20mg daily, with effects usually seen within 4-6 weeks.
- Treatment should continue for at least 6-12 months after symptom resolution to prevent relapse.
Monitoring and Lifestyle Modifications
Parents should be informed about the FDA black box warning regarding increased suicidal thoughts, particularly in the first few weeks of treatment, necessitating close monitoring 1.
- Regular follow-up appointments should occur every 1-2 weeks initially to assess response and side effects.
- Lifestyle modifications including regular physical activity, adequate sleep, and stress management techniques are important adjuncts to treatment.
- SSRIs work by increasing serotonin levels in the brain, which helps regulate mood, while therapy provides adolescents with coping skills and addresses negative thought patterns that contribute to depression.
From the FDA Drug Label
- 1 Major Depressive Disorder Adolescents The efficacy of Escitalopram as an acute treatment for major depressive disorder in adolescent patients was established in an 8-week, flexible-dose, placebo-controlled study that compared Escitalopram 10-20 mg/day to placebo in outpatients 12 to 17 years of age inclusive who met DSM-IV criteria for major depressive disorder 1.1 Major Depressive Disorder Escitalopram is indicated for the acute and maintenance treatment of major depressive disorder in adults and in adolescents 12 to 17 years of age [see Clinical Studies (14. 1)]
The treatment of depression in adolescents can be done with escitalopram (PO), as it has been established as an effective acute treatment for major depressive disorder in adolescent patients 12 to 17 years of age. The recommended dose is 10-20 mg/day.
- Key points:
From the Research
Treatment Options for Adolescent Depression
- Medication monotherapy, specifically with selective serotonin reuptake inhibitors, is supported by large clinical trials in adolescents 3
- Cognitive behavior therapy (CBT) and interpersonal therapy are reasonable options as monotherapies for mild to moderate depression 3
- The combination of medication and CBT is superior to medication alone for accelerating the pace of treatment response and remission 3
Cognitive Behavioral Therapy (CBT) for Adolescent Depression
- CBT is a well-established treatment of depression in children and adolescents, but treatment trials for adolescents with suicidality are few in number 4
- CBT containing a combination of behavioral activation and challenging thoughts component or the involvement of caregiver(s) in intervention were associated with better outcomes for youth on the long term 5
- CBT is effective for youth with a (subclinical) depression, with moderate-quality evidence found for CBT reducing depressive symptoms at the end of treatment and at follow-up 5
Comparison of Treatment Modalities
- No significant difference was found between CBT only, CBT+Medication, or Medication alone in reducing the duration of major depressive episodes, lessening internalizing and externalizing symptoms 6
- CBT had significantly greater effect at the longest follow-up than CBT+Medication for global functioning 6
- CBT+Medication had the highest p-score for depression, short- and long-term effects, and internalizing and externalizing symptoms long-term effects 6