What is the recommended treatment for a 12-year-old female with depression?

Treatment of Depression in a 12-Year-Old Female

For a 12-year-old female with depression, initiate combination therapy with fluoxetine (starting at 10 mg daily) plus cognitive behavioral therapy (CBT), as this approach achieves a 71% response rate compared to 35% with placebo alone. 1, 2

Initial Assessment Requirements

Before initiating treatment, complete a structured assessment focusing on:

• Severity of depressive symptoms using a validated screening tool (PHQ-9 or similar) 1
• Suicide risk assessment including specific questions about suicidal ideation, plans, and prior attempts 1
• Comorbid conditions including anxiety disorders, substance use, ADHD, and other psychiatric diagnoses 1
• Psychosocial stressors such as family crises, abuse, neglect, trauma history, or school problems 1
• Family history of depression, bipolar disorder, or suicide-related behaviors 1

First-Line Treatment Algorithm

Combination Therapy (Preferred)

Start fluoxetine 10 mg daily in the morning plus weekly CBT sessions. 2, 3

• Fluoxetine is the only FDA-approved antidepressant for children and adolescents with depression 2, 3
• Increase fluoxetine by 10-20 mg increments at no less than weekly intervals based on response and tolerability 2
• Target effective dose is typically 20 mg daily, with maximum dose of 60 mg daily 2
• Combined fluoxetine plus CBT demonstrates 71% response rate versus 35% for placebo, significantly superior to either treatment alone 1, 2

Monotherapy Options (If Combination Not Feasible)

If CBT is unavailable or declined:

• Start fluoxetine monotherapy using the same dosing schedule above 2, 3
• SSRIs alone show response rates of 2.4% to 25% above placebo across studies 1

If medication is declined for mild depression:

• Consider CBT monotherapy, though response rate is only 43.2% versus 34.8% for placebo 1, 2
• For mild depression specifically, a period of active support and monitoring for 6-8 weeks before formal treatment may be appropriate 2

Critical Safety Monitoring

Assess the patient in person within 1 week of starting fluoxetine, then regularly thereafter. 2

At each visit, evaluate:

• Suicidal ideation and behavior (highest risk in first months of treatment and after dose changes) 1, 2, 4
• Behavioral activation or agitation especially in the first month 4
• Ongoing depressive symptoms using standardized rating scales 2, 4
• Adverse effects including fatigue, sleep disturbance, gastrointestinal symptoms 4, 3
• Treatment adherence and medication timing 2, 4
• New or ongoing environmental stressors 2

FDA Black Box Warning

All antidepressants carry an increased risk of suicidal thinking and behavior in children and adolescents during early treatment, though no completed suicides were reported in controlled trials. 1, 2, 4

Alternative SSRI Options

If fluoxetine is not tolerated:

• Escitalopram is FDA-approved for adolescents aged 12 years and older, showing superiority to placebo in improving depression symptoms 1, 2
• Sertraline may be considered: start at 25 mg, effective dose 50 mg, maximum 200 mg daily 2, 4
• Allow 1-2 weeks between dose adjustments to properly assess tolerability 4
• Sertraline has a shorter half-life than fluoxetine, potentially reducing persistent side effects 4

Treatment Response Timeline

Do not conclude treatment is ineffective before completing an adequate trial: 8 weeks at optimal dosage. 2

• Improvement may begin within 2-4 weeks of starting medication 4
• Full response takes 8-12 weeks to achieve 4
• If no improvement after 6-8 weeks despite adequate treatment, explore poor adherence, comorbid disorders, or ongoing conflicts/abuse before changing the treatment plan 2

Management of Partial or Non-Response

For partial response to maximum tolerated SSRI dosage:

• Add evidence-based psychotherapy (CBT or interpersonal therapy) if not already initiated 2

For non-response after adequate trial:

• Reassess diagnosis and consider comorbid conditions 2
• Switch to alternative SSRI (escitalopram or sertraline) 2, 4
• Refer to child psychiatry if no improvement after second SSRI trial 4

Collaborative Care Model

Consider implementing a collaborative care approach that includes:

• Parent involvement in treatment planning and monitoring 1, 2
• Choice of treatment type (medication, psychotherapy, or both) 1, 2
• Regular follow-up with depression care managers 1, 2
• This model shows greater reductions in depressive symptoms at 6 and 12 months compared to usual care, with significantly higher response and remission rates 1, 2

Maintenance Treatment

Continue medication for at least 6-12 months after achieving response. 2

• The greatest risk of relapse occurs in the first 8-12 weeks after discontinuation 2
• When discontinuing, slowly taper all SSRIs to prevent withdrawal effects 2
• Gradually tapering while providing concurrent CBT can decrease relapse risk 5

Immediate Consultation Triggers

Immediately consult child psychiatry for:

• Moderate or severe depression with active suicidality 2
• Coexisting substance abuse 2
• Psychotic symptoms 2
• Suspected bipolar disorder 1

Common Pitfalls to Avoid

• Do not use higher starting doses of SSRIs, as they are associated with increased risk of deliberate self-harm 2
• Do not use benzodiazepines due to risk of disinhibition in younger patients 4
• Failing to address comorbid conditions, poor adherence, or ongoing environmental stressors will undermine treatment response 2
• Do not administer SSRIs at night if daytime fatigue is a concern; morning dosing may help minimize this side effect 4

Adjunctive Interventions

Include in all treatment plans:

• Physical exercise 2
• Sleep hygiene 2
• Adequate nutrition 2
• School-based supports including individual education plans when appropriate 1