What can I prescribe for a depressed teenager?

Treatment of Depression in Adolescents

For a depressed teenager, prescribe fluoxetine as the first-line antidepressant medication, starting at 10 mg daily, combined with cognitive-behavioral therapy (CBT) or interpersonal psychotherapy for adolescents (IPT-A) for moderate to severe depression. 1, 2

Treatment Algorithm Based on Depression Severity

Mild Depression

• Consider a period of active support and monitoring (6-8 weeks) before initiating formal treatment. 3
• If treatment becomes necessary, start with psychotherapy alone (CBT or IPT-A) rather than medication. 1
• Incorporate physical exercise, sleep hygiene, and adequate nutrition as foundational interventions. 1, 2

Moderate to Severe Depression

• Initiate combination treatment with both an SSRI and evidence-based psychotherapy from the outset, as this produces superior outcomes compared to either treatment alone. 1, 4
• Fluoxetine is the only FDA-approved antidepressant for adolescents and has the strongest evidence base, with response rates of 47-69% versus 33-57% for placebo. 1
• Start fluoxetine at 10 mg daily and increase by 10-20 mg increments at no less than weekly intervals, with an effective dose typically 20 mg daily (maximum 60 mg daily). 2

Alternative SSRI Options

• Escitalopram is FDA-approved for adolescents aged 12 years and older and may be used as an alternative. 2, 5, 4
• Sertraline may be considered with a starting dose of 25 mg, effective dose of 50 mg, and maximum dose of 200 mg. 2
• Avoid duloxetine, venlafaxine, and paroxetine as first-line choices due to higher rates of intolerable side effects. 1

Critical Monitoring Requirements

Initial Phase (First 2 Weeks)

• Assess the patient in person within 1 week of treatment initiation. 2
• Monitor closely for emergence of suicidal ideation or behavior, as the highest risk occurs during the first few months of treatment. 1, 6, 4
• Watch for behavioral activation (agitation, aggression, worsening depression, anxiety, insomnia, impulsivity), which can herald a switch to mania or increased suicidality. 6

Ongoing Monitoring

• Continue regular assessments for at least 3 months, evaluating depressive symptoms, suicide risk, adverse effects, treatment adherence, and environmental stressors. 2, 6
• Reassess diagnosis and treatment if no improvement occurs after 6-8 weeks. 3, 7

Evidence for Psychotherapy

CBT and IPT-A have demonstrated effectiveness, though CBT alone showed only a 43.2% response rate in the TADS study, which was not significantly different from placebo (34.8%). 3, 2 This finding underscores why combination treatment is preferred for moderate to severe depression.

• IPT-A has shown significant effects on reducing depression severity, suicidal ideation, and hopelessness compared to treatment as usual. 3, 1
• Adolescents with higher baseline interpersonal difficulties show greater and more rapid symptom reduction with IPT-A. 3

When to Consult Mental Health Specialists

• Immediately consult for moderate or severe depression with complicating factors: coexisting substance abuse, psychosis, or active suicidality. 3
• If no improvement after 6-8 weeks despite adequate treatment, explore poor adherence, comorbid disorders, or ongoing conflicts/abuse before changing the treatment plan. 3, 7
• For partial response to maximum tolerated SSRI dosage, add evidence-based psychotherapy if not already initiated. 3, 7

Maintenance Treatment

• Continue antidepressant treatment for 6-12 months after full symptom resolution to prevent relapse. 2, 7
• The greatest risk of relapse occurs in the first 8-12 weeks after discontinuation. 2
• Slowly taper all SSRIs when discontinuing to avoid withdrawal effects. 1, 2

Common Pitfalls to Avoid

• Never start at adult doses—higher starting doses are associated with increased risk of deliberate self-harm. 1, 2
• Do not conclude treatment is ineffective before completing an adequate trial: 8 weeks at optimal dosage for antidepressants. 3
• Inadequate follow-up is a critical error—monthly monitoring is essential for 6-12 months after symptom resolution. 7
• Failing to address comorbid conditions, poor adherence, or ongoing environmental stressors will undermine treatment response. 3, 7