SSRI Selection for a 17-Year-Old
Fluoxetine is the recommended first-line SSRI for a 17-year-old, starting at 10 mg daily and increasing to 20 mg daily after 2 weeks if well-tolerated, with a therapeutic range of 20-60 mg daily. 1, 2
FDA-Approved Options
- Fluoxetine is the only SSRI with FDA approval for depression in children and adolescents (though not specifically for anxiety disorders) 2
- Escitalopram has FDA approval for adolescents aged 12 years and older for depression 1
- All other SSRIs remain off-label for this age group 1
Evidence-Based Efficacy
For depression specifically:
- Fluoxetine demonstrated 56% response rate versus 33% placebo in adolescents aged 12-17 years 3
- Escitalopram showed superiority to placebo in improving depression symptoms in adolescents but not in younger children 1
- Fluoxetine combined with cognitive behavioral therapy (CBT) achieved 71% response rate versus 35% placebo, making combination therapy preferable to either treatment alone 1, 2
Recommended Dosing Protocol for Fluoxetine
Initial dosing:
- Start with 10 mg daily as a "test dose" to monitor for initial adverse effects such as increased anxiety or agitation 2
- After 2 weeks, if well-tolerated, increase to 20 mg daily 2
Titration schedule:
- Make dose adjustments at 3-4 week intervals due to fluoxetine's long half-life 2
- Therapeutic range: 20-60 mg daily 2
- Administer once daily in the morning 2
Expected timeline:
- Clinically significant improvement typically seen by week 6 2
- Maximal improvement by week 12 or later 2
Alternative SSRI Options (Off-Label)
If fluoxetine is not tolerated or contraindicated, consider these alternatives based on guideline recommendations 1:
Escitalopram:
- Starting dose: 10 mg daily
- Increments: 5 mg
- Effective dose: 10 mg
- Maximum: 20 mg daily
Sertraline:
- Starting dose: 25 mg daily (per FDA label for adolescents aged 13-17 with OCD) 4
- After one week, increase to 50 mg daily 4
- Effective dose: 50 mg
- Maximum: 200 mg daily 1, 4
Citalopram:
- Starting dose: 10 mg daily
- Increments: 10 mg
- Effective dose: 20 mg
- Maximum: 60 mg daily 1
Avoid paroxetine as it is not recommended to be started in primary care for adolescents 1
Critical Safety Monitoring
Black box warning requirements:
- All SSRIs carry FDA black box warning for suicidal thinking and behavior through age 24 years 2
- Close monitoring for suicidality is mandatory, especially during the first months of treatment and following dosage adjustments 1, 2
- Contact (in-person or telephone) should occur after treatment initiation to review adherence and current status 1
Common adverse effects to monitor:
- Dry mouth, nausea, diarrhea, headache, somnolence, insomnia, dizziness, changes in appetite, and fatigue 2
- Most adverse effects emerge within the first few weeks of treatment 2
Serious but rare adverse effects:
- Suicidal thinking, behavioral activation/agitation, hypomania, mania, and serotonin syndrome 2
- Risk of behavioral activation is higher if SSRI started at higher doses rather than normal starting doses 1
Important Clinical Caveats
Contraindications and precautions:
- SSRIs should be avoided in patients with history of bipolar depression due to risk of mania 1
- If antidepressant-induced mania occurs, this is characterized as substance-induced per DSM criteria 1
- All SSRIs are contraindicated with monoamine oxidase inhibitors (MAOIs) 1
Discontinuation:
- All SSRIs must be slowly tapered when discontinued to avoid withdrawal effects 1, 2
- Fluoxetine's long half-life essentially precludes withdrawal phenomenon compared to other SSRIs 5
Parental involvement:
- Parental oversight of medication regimens is crucial for adolescents 2
- Parents should be involved in monitoring for adverse effects using checklists 1
Drug interactions:
- Fluoxetine is an inhibitor of cytochrome P450 2D6 and other CYP enzymes, increasing potential for drug interactions, though most are not clinically important 5