What is the treatment plan for a 16-year-old female patient presenting with symptoms of depression, including lack of motivation, sadness, and anhedonia?

Treatment Plan for a 16-Year-Old Female with Depression

This adolescent requires immediate comprehensive suicide risk assessment, followed by evidence-based psychotherapy as first-line treatment, with consideration of SSRI medication if symptoms are moderate-to-severe or if psychotherapy alone is insufficient. 1

Immediate Safety Assessment

• Directly ask about suicidal ideation using specific questions: "Have you ever thought about killing yourself or wished you were dead?" followed by "Have you ever done anything on purpose to hurt or kill yourself?" 1
• Place these questions in the middle or toward the end of depression symptom screening to maintain rapport 1
• If any positive response, immediately assess for specific plans, access to firearms, intent, and timeline 1
• Safety takes precedence over confidentiality—explain this to both patient and family at the outset 1
• Arrange immediate mental health evaluation if suicidal ideation is present, through psychiatric hospitalization, emergency department transfer, or same-day mental health appointment 2
• Develop a safety plan that includes restricting lethal means (especially firearms), engaging a concerned third party, and establishing emergency communication mechanisms 1

Diagnostic Confirmation and Severity Assessment

• Use PHQ-9 as the primary screening tool (sensitivity 89.5%, specificity 77.5% at cutoff ≥11) 3
• Screening alone does not establish diagnosis—conduct direct clinical interview using DSM-5 criteria to confirm major depressive disorder 3
• Assess for the core symptoms: depressed or irritable mood, anhedonia (loss of interest/pleasure), changes in sleep/appetite/energy, guilt/worthlessness, concentration difficulties, psychomotor changes, and suicidal thoughts 1
• Evaluate functional impairment across school, home, and peer relationships 1
• Screen for bipolar disorder risk before initiating any antidepressant, as treating unrecognized bipolar disorder with antidepressants alone may precipitate manic episodes 4
• Assess for comorbid conditions: anxiety disorders, substance use, trauma history, and psychotic symptoms 1, 3
• Obtain collateral information from parents when possible 3

Baseline Laboratory Testing

• Obtain thyroid function studies (TSH) to rule out thyroid-induced depressive symptoms 3
• Complete blood count, liver function tests, and metabolic panel before initiating any antidepressant medication 3
• These establish baseline values for monitoring treatment-related adverse effects 3

Treatment Algorithm Based on Severity

Mild Symptoms (PHQ-9: 1-7)

• Provide psychoeducation about depression and normal stress responses 3
• Ensure adequate coping skills and access to resources 3
• Schedule reassessment at future visits, particularly given her age and symptom profile 3

Moderate Symptoms (PHQ-9: 8-14)

• Initiate evidence-based psychotherapy as first-line treatment 1, 5
• Effective modalities include cognitive behavioral therapy (CBT), behavioral activation, interpersonal therapy, or problem-solving therapy (effect sizes 0.50-0.73) 3
• Consider referral to psychology or psychiatry for diagnostic evaluation and treatment initiation 3
• If psychotherapy alone is insufficient after 8 weeks, add SSRI medication 1

Moderate-to-Severe/Severe Symptoms (PHQ-9: 15-27)

• Immediate referral to psychology and/or psychiatry for diagnosis and treatment 3
• Initiate combination treatment with both psychotherapy and SSRI medication, as combination therapy is superior to either alone for severe depression 6
• Assess for risk of harm to self or others immediately—any endorsement of specific plans or intent requires emergency intervention 3

Pharmacotherapy Considerations (If Indicated)

SSRI Selection and Dosing

• Fluoxetine is FDA-approved for adolescent major depressive disorder and has the most evidence in this age group 4
• Alternative: Sertraline starting at 25 mg daily for one week, then increase to 50 mg daily 7
• For adolescents 13-17 years, sertraline can be initiated at 50 mg daily 7
• Maximum dose: 200 mg/day for both fluoxetine and sertraline, with dose changes no more frequently than weekly given 24-hour elimination half-life 7

Critical Safety Monitoring for SSRIs

• Black box warning: Increased risk of suicidal thoughts and behaviors in adolescents and young adults during first few months of treatment or with dose changes 7, 4
• Monitor biweekly or monthly until symptoms remit for: new or worsening depression, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, or mania 7, 4
• These symptoms may represent precursors to emerging suicidality 4
• Obtain laboratory tests before each medication adjustment and monitor for hyponatremia (especially concerning in adolescents), liver function changes, and metabolic effects 3
• Given this patient's prominent anhedonia, be aware that anhedonia predicts poorer recovery and longer time to remission with SSRI treatment 8

Medication Management

• Schedule follow-up within 48-72 hours of treatment initiation, then weekly initially 9
• After 8 weeks, if symptom reduction is poor despite good compliance, alter treatment course by adding psychotherapy, changing medication, or increasing dose 1
• Assess compliance, side effects, and satisfaction at each visit 1

Psychotherapy Implementation

• Cognitive behavioral therapy (CBT) is as effective as medication for major depression and should be first-line for mild-to-moderate symptoms 3
• Other effective modalities: behavioral activation (particularly relevant for anhedonia), interpersonal therapy, problem-solving therapy, brief psychodynamic therapy, mindfulness-based therapy 3
• Therapy should be delivered by licensed mental health professionals using relevant treatment manuals 1
• Include content on cognitive change, behavioral activation, biobehavioral strategies, education, and relaxation strategies 1
• For group therapy options: structured sessions led by licensed professionals covering stress reduction, positive coping, enhancing social support, and health behavior change 1

Family Involvement and Education

• Provide developmentally appropriate psychoeducation to both patient and family about depression causes, symptoms, impairments, and expected treatment outcomes 1
• Educate families about warning signs: new or sudden changes in mood, behavior, actions, thoughts, or feelings, especially if severe 7
• Discuss limits of confidentiality explicitly—safety concerns override confidentiality 1
• Be aware that family members may have negative reactions (sadness, anger, denial) to the diagnosis 1
• Instruct parents to monitor daily for emergence of agitation, irritability, unusual behavior changes, and suicidality 4

Treatment Goals and Monitoring

• Set specific, measurable treatment goals in key functioning areas: school performance, peer relationships, family interactions, and self-care 1
• Written treatment plans with specific goals improve adherence and outcomes 1
• Monitor for treatment adherence—adolescents with depression often lack motivation to follow through on referrals 1
• If compliance is poor, assess and address obstacles to compliance or discuss alternative interventions 1

Duration of Treatment

• Acute episodes of major depressive disorder require several months or longer of sustained treatment beyond initial response 7
• Continue effective treatment for at least 6-12 months after symptom remission to prevent relapse 7
• Periodically reassess need for maintenance treatment 7
• When discontinuing medication, taper gradually while providing concurrent CBT to decrease relapse risk 6
• Abrupt discontinuation can cause withdrawal symptoms including anxiety, irritability, mood changes, restlessness, sleep changes, headache, sweating, nausea, dizziness, and electric shock-like sensations 7

School Coordination

• Establish partnerships with school personnel to monitor functioning in academic settings 1
• Consider 504 plan or IEP evaluation if depression significantly impacts academic performance 9
• Identify school counselor or trusted adult for check-ins 9

Common Pitfalls to Avoid

• Do not rely on screening scores alone for diagnosis—false-positive rates are 60-76% in primary care settings 3
• Never use "no-suicide contracts"—they are not proven effective and may impair therapeutic alliance 2, 9
• Do not dismiss suicidal statements as attention-seeking or unimportant 1
• Do not overlook comorbid anxiety, which affects treatment selection and outcomes 3
• Do not underestimate the prognostic significance of anhedonia—it predicts poorer recovery and may require dopamine-targeting strategies if SSRI response is inadequate 10, 8
• Do not initiate antidepressants without adequate screening for bipolar disorder risk 4
• For adolescents 18-29 years, be particularly vigilant about increased suicidal behavior risk with SSRIs 1

Follow-Up Schedule

• First follow-up within 48-72 hours of treatment initiation 9
• Weekly visits initially, then biweekly or monthly until symptoms remit 1, 9
• Maintain contact even after referral to mental health specialists—collaborative care results in greater symptom reduction 2
• At each visit: assess treatment adherence, side effects, symptom improvement, functional status, and safety 1