What is the recommended initial medication for a 15-year-old patient with depression?

Initial Medication for Depression in a 15-Year-Old

Fluoxetine is the recommended first-line antidepressant for a 15-year-old with depression, started at 10 mg daily and titrated to an effective dose of 20 mg daily (maximum 60 mg daily), with close monitoring for suicidal ideation within the first week of treatment. 1, 2

Why Fluoxetine Specifically

• Fluoxetine is the only SSRI with FDA approval for children and adolescents with depression (approved for ages 8 years and older), making it the strongest regulatory-backed choice. 1, 2

• Fluoxetine has the most robust evidence base among all antidepressants for this age group, with consistent efficacy demonstrated across three trials showing significant reduction in depression symptoms (CDRS-R treatment effect -5.63,95% CI -7.38 to -3.88) and treatment response (RR 1.86,95% CI 1.49 to 2.32). 3

• The World Health Organization specifically recommends fluoxetine—but not other SSRIs or tricyclic antidepressants—for adolescents with depression in non-specialist settings. 4

Dosing Algorithm

• Start fluoxetine at 10 mg daily (not 20 mg, as higher starting doses increase risk of deliberate self-harm). 2

• Increase by 10-20 mg increments at intervals of no less than 1 week based on response and tolerability. 2

• Target effective dose is typically 20 mg daily, with maximum dose of 60 mg daily if needed. 2

Alternative SSRIs (Second-Line Options)

• Escitalopram is FDA-approved for adolescents aged 12-17 years and showed superiority to placebo specifically in adolescents (but NOT in children under 12). 4, 1

• Sertraline may be considered with starting dose of 25 mg, effective dose of 50 mg, and maximum of 200 mg daily, though evidence is less robust than fluoxetine. 2

• Paroxetine should be avoided in this population despite FDA approval in adults, as efficacy data in adolescents is insufficient and concerns about suicidality are present. 5, 6

Critical Safety Monitoring Requirements

• Assess the patient in person within 1 week of starting medication to evaluate depressive symptoms, suicide risk, adverse effects, adherence, and environmental stressors. 4, 2

• Continue regular monitoring thereafter, as SSRIs carry an FDA black box warning for increased risk of suicidal thinking and behavior in children and adolescents during early treatment (RR 1.80,95% CI 1.19 to 2.72). 4, 3

• Adolescents on fluoxetine must be monitored closely for suicide ideas and behavior, with specialist support obtained when available. 4

What NOT to Prescribe

• Tricyclic antidepressants (including nortriptyline, imipramine) should never be prescribed to adolescents with depression due to high lethal potential in overdose, particularly dangerous in suicidal youth, and demonstrated inferiority to SSRIs in efficacy. 1, 6

• Antidepressants should not be used at all in children aged 6-12 years with depression in non-specialist settings according to WHO guidelines. 4

Combining with Psychotherapy

• Combined fluoxetine plus cognitive behavioral therapy (CBT) achieved 71% response rate versus 35% for placebo, significantly superior to either treatment alone (fluoxetine alone: modest benefit; CBT alone: 43.2% response rate). 2

• For moderate to severe depression, strongly consider initiating both medication and evidence-based psychotherapy (CBT or interpersonal therapy) simultaneously rather than sequentially. 2

Treatment Duration and Reassessment

• Do not conclude treatment is ineffective before completing 8 weeks at optimal dosage. 2

• 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

• Maintain medication for at least 6-12 months after response, as greatest relapse risk occurs in the first 8-12 weeks after discontinuation. 2

• Taper slowly when discontinuing to prevent withdrawal effects. 2

Common Pitfalls to Avoid

• Starting with doses that are too high increases self-harm risk—always start low at 10 mg fluoxetine. 2

• Failing to address comorbid conditions (substance abuse, psychosis, active suicidality), poor adherence, or ongoing environmental stressors will undermine treatment response and requires immediate specialist consultation. 2

• Assuming all SSRIs are equivalent—only fluoxetine has consistent evidence in this age group. 1, 3