What is the first line of treatment for a 17-year-old female with depression and anxiety?

From the Guidelines

For a 17-year-old female with depression and anxiety, the first-line treatment approach should be a combination of psychotherapy (particularly cognitive behavioral therapy) and medication, prioritizing the treatment of depressive symptoms or using a unified protocol that combines cognitive behavior therapy treatments for depression and anxiety. This approach is supported by the most recent and highest quality study, which emphasizes the importance of treating depressive symptoms first or using a unified protocol for patients with symptoms of both depression and anxiety 1. The study, published in the Journal of Clinical Oncology in 2023, provides a strong recommendation (Type: Evidence based; benefits outweigh harms; Evidence quality: High; Strength of recommendation: Strong) for this approach.

When it comes to medication, fluoxetine (Prozac) is typically considered the first-choice medication for adolescents with depression, as it is the only SSRI FDA-approved for depression in this age group, with strong evidence for both depression and anxiety 1. A common regimen for fluoxetine is starting at 10mg daily for one week, then increasing to 20mg daily, with effects typically taking 4-6 weeks to fully manifest.

Key considerations for treatment include:

• Regular follow-up appointments (initially every 2-4 weeks) to monitor for side effects, particularly increased suicidal thoughts, which can occur in the first few weeks of treatment.
• Treatment should continue for at least 6-12 months after symptom improvement to prevent relapse.
• The combination approach of psychotherapy and medication is recommended because adolescent depression often responds better to combined therapy than either treatment alone, and fluoxetine has the strongest safety and efficacy data in this age group compared to other antidepressants.

From the FDA Drug Label

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 1.2 Generalized Anxiety Disorder Escitalopram is indicated for the acute treatment of Generalized Anxiety Disorder (GAD) in adults 14. 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

The first line of treatment for a 17-year-old female with depression and anxiety could be escitalopram (PO), as it is indicated for the acute and maintenance treatment of major depressive disorder in adolescents 12 to 17 years of age 2. However, it is essential to note that escitalopram is only indicated for the acute treatment of Generalized Anxiety Disorder (GAD) in adults, and its use in adolescents with anxiety should be approached with caution.

• Key points:
  • Escitalopram is indicated for major depressive disorder in adolescents 12 to 17 years of age.
  • Escitalopram has shown statistically significant greater mean improvement compared to placebo on the Children’s Depression Rating Scale - Revised (CDRS-R) in adolescent patients 2.
  • The efficacy of escitalopram in the acute treatment of major depressive disorder in adolescents was established, in part, on the basis of extrapolation from the 8-week, flexible-dose, placebo-controlled study with racemic citalopram 20-40 mg/day 2.

From the Research

Treatment Options for Depression and Anxiety in a 17-Year-Old Female

• The first line of treatment for depression and anxiety in adolescents may include cognitive-behavioral therapy (CBT) or a selective serotonin reuptake inhibitor (SSRI) 3.
• A study found that the combination of fluoxetine with CBT was the most effective treatment for adolescents with major depressive disorder, with a response rate of 71.0% 3.
• Another study compared interpersonal psychotherapy (IPT) and CBT for major depressive disorder in a community-based psychiatric outpatient clinic, and found that IPT was noninferior to CBT, with a reliably improved rate of 53.5% for IPT and 51.0% for CBT 4.
• For patients with concomitant borderline personality disorder, combined therapy with fluoxetine and IPT or fluoxetine and CT was found to be efficacious in treating major depression, with differences between CT and IPT concerning specific features of subjective quality of life and interpersonal problems 5.
• Higher levels of anxiety, both prior to monotherapy and prior to beginning combination treatment, predicted poorer outcomes for both treatment groups 6.
• The combination of medication and psychotherapy is preferred for severe depression, and treatment history, comorbidities, costs, and risk of adverse effects should be considered when choosing an antidepressant medication 7.

Considerations for Treatment

• The order in which CBT and antidepressant medication are sequentially combined does not appear to affect outcomes 6.
• Addition of an antidepressant is an effective approach to treating residual symptoms for patients who do not achieve remission with CBT, as is adding CBT after antidepressant monotherapy 6.
• Patients who do not respond to one treatment modality warrant consideration for addition of the alternative modality 6.
• Gradually tapering the dosage of an antidepressant while concurrently providing CBT can decrease the risk of relapse or recurrence of depressive symptoms 7.