Recommended Medications for Depression in Teenagers
Fluoxetine is the first-line medication treatment for adolescents with depression, having the strongest evidence base and FDA approval for this population. 1, 2
Treatment Algorithm Based on Severity
- For mild depression in adolescents, consider a period of active support and monitoring before starting medication, with psychotherapy (CBT or IPT-A) as the initial treatment if intervention is needed 2
- For moderate to severe depression, fluoxetine is recommended as the first-line pharmacological treatment, either alone or in combination with psychotherapy 1, 3
- Combination treatment with fluoxetine and cognitive-behavioral therapy (CBT) offers the most favorable outcomes for adolescents with major depressive disorder, with response rates of 71% compared to 60.6% for fluoxetine alone 3
Specific SSRI Recommendations
- Fluoxetine has the strongest evidence base with multiple positive clinical trials and FDA approval for children and adolescents with depression 1, 4
- Starting dose for fluoxetine should be 10 mg/day for 1 week, then increased to 20 mg/day 4
- Escitalopram is also FDA-approved for adolescents aged 12-17 years with major depressive disorder 5
- Recommended starting dose for escitalopram is 10 mg once daily, which may be increased to 20 mg after a minimum of three weeks if needed 5
- Other SSRIs that have shown efficacy in clinical trials include sertraline and citalopram, though with less robust evidence than fluoxetine 1
Dosing and Administration Guidelines
- Start with lower doses than those used for adults and titrate slowly 2, 5
- SSRIs should be administered once daily, with or without food 5
- Medication dosages for adolescents (starting/effective/maximum in mg):
Monitoring and Safety Considerations
- Close monitoring is essential during the first few weeks of treatment, particularly for suicidal thoughts and behaviors 1
- Ideally, patients should be assessed in person within 1 week of starting medication 1
- At each follow-up, assess: ongoing depressive symptoms, suicide risk, adverse effects, medication adherence, and environmental stressors 1
- Common adverse effects include nausea, headaches, and behavioral activation 1
- Duloxetine, venlafaxine, and paroxetine have higher rates of intolerable side effects and should not be first-line choices 1, 2
- Paroxetine is specifically not recommended to be started in primary care settings 1
Duration of Treatment
- Maintenance treatment should continue for at least 6-12 months after symptom resolution 1, 6
- Risk of relapse is highest in the first 8-12 weeks after discontinuing medication 1
- Studies suggest longer medication continuation periods (possibly 1 year) may be necessary for relapse prevention 1, 6
- When discontinuing, SSRIs should be slowly tapered to avoid withdrawal effects 1
Clinical Pitfalls to Avoid
- Starting antidepressants at higher than recommended doses increases the risk of adverse events, including suicidality 1, 2
- Inadequate monitoring during the initial treatment phase can miss emerging adverse effects 1
- Premature discontinuation of medication before adequate trial duration (8-12 weeks) 1, 7
- Failure to screen for bipolar disorder before starting antidepressants, as SSRIs may trigger manic episodes in predisposed individuals 1, 5
- Using tricyclic antidepressants, which have greater lethal potential in overdose and lack efficacy evidence in adolescents 1
Special Considerations
- For adolescents with comorbid bipolar disorder, antidepressants should only be used as adjuncts to mood stabilizers 1
- Family history of treatment response may predict response in offspring 1
- Recurrence rates for depression in adolescents are high (approximately 40% within 12 months), even with treatment 6
- Younger age, lower severity of depressive symptoms, higher family functioning, and fewer comorbid diagnoses are associated with better recovery 6