What is the appropriate management for a 16-year-old patient with a past medical history (PMH) of depression, currently treated with Prozac (fluoxetine) 20mg, who reports a good response to treatment and no adverse effects, and is requesting medication refills?

From the Guidelines

The patient's current treatment regimen of Prozac 20 mg daily should be continued, with regular monitoring for adverse events and suicidal ideation, as her depression appears well-controlled on this medication. The patient is a 16-year-old female with a past medical history of depression who presents to clinic today accompanied by her father for medication management. She is currently taking Prozac 20 mg daily with good response and is requesting medication refills. The patient denies any suicidal ideation, recent alcohol use, drug use, or medication side effects. She reports having a good academic year and does not feel any need for treatment changes at this time. The patient has successfully completed counseling therapy and understands she can resume therapy if needed in the future. According to the guidelines for adolescent depression in primary care, PC clinicians should monitor for the emergence of adverse events during antidepressant treatment (SSRIs) 1. The FDA recommends close monitoring for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of treatment or at times of dose changes 1.

Some key points to consider in the management of this patient include:

• Monitoring for adverse events and suicidal ideation, as recommended by the FDA and the guidelines for adolescent depression in primary care 1
• Continuing treatment for 6 to 12 months after the full resolution of depressive symptoms, as recommended by the American Academy of Child and Adolescent Psychiatry and the guidelines for adolescent depression in primary care 1
• Regular follow-up, either in person or by telephone, to review the patient's and family's understanding of and adherence to the treatment plan, as recommended by the guidelines for adolescent depression in primary care 1
• Considering the patient's history of depression and the potential for recurrence, long-term treatment may be necessary to prevent relapse, as recommended by the American College of Physicians 1.

Overall, the patient's current treatment regimen appears to be effective, and with regular monitoring and follow-up, it is likely that her depression will remain well-controlled.

From the FDA Drug Label

In the short–term (8 to 9 week) controlled clinical trials of fluoxetine supporting its effectiveness in the treatment of major depressive disorder, patients were administered fluoxetine doses of 10 to 20 mg/day Treatment should be initiated with a dose of 10 or 20 mg/day. After 1 week at 10 mg/day, the dose should be increased to 20 mg/day.

The patient is a 16-year-old with a history of depression, currently being treated with Prozac 20mg with a good response. The patient's current dose is within the recommended range for pediatric patients.

• The patient has had no thoughts of suicide, no recent alcohol use, no drug use, and no medication side effects.
• The patient reports having a good school year and denies any need for a change in treatment at this time.
• The patient is requesting refills and reports graduating from counseling. The patient's current treatment regimen is appropriate, and refills can be provided as needed, with continued monitoring for any changes in the patient's condition 2.

From the Research

History of Present Illness (HPI)

The patient is a 16-year-old female with a past medical history (PMH) of depression. She is currently taking Prozac 20mg with a reported good response to the treatment.

• The patient denies any thoughts of suicide, recent alcohol use, or drug use.
• She also reports no medication side effects.
• The patient is having a good school year and does not feel the need for any changes to her current treatment plan at this time.
• She has graduated from counseling and is aware that she can return to it if needed.
• The patient is requesting a refill of her current medication.

Relevant Studies

Studies have shown that fluoxetine, the active ingredient in Prozac, is effective in treating depression in adolescents 3. A study published in 2004 found that the combination of fluoxetine and cognitive-behavioral therapy (CBT) was the most effective treatment for adolescents with major depressive disorder 3. Another study published in 2013 compared the efficacy of fluoxetine to other antidepressants and found that it was as effective as tricyclic antidepressants (TCAs) but less effective than some other selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) 4.

• A 2004 study found that fluoxetine has a favorable tolerability profile compared to TCAs 5.
• A 2019 case report highlighted the importance of recognizing persistent genital arousal disorder (PGAD) in adolescents, which can be treated with SSRIs such as fluoxetine 6.
• A 2001 review of fluoxetine's therapeutic potential in treating depression associated with physical illness found that it was effective in improving symptoms of depression in patients with HIV/AIDS, diabetes mellitus, and stroke 7.

Treatment Considerations

The patient's current treatment plan with Prozac 20mg has been effective in managing her depression, and she has not reported any side effects.

• The patient's denial of suicidal thoughts, substance use, and medication side effects suggests that her current treatment plan is suitable for her.
• The fact that she has graduated from counseling and is aware that she can return to it if needed suggests that she has a support system in place.
• The request for a refill of her current medication indicates that she is committed to her treatment plan.