What is the recommended management approach for an adolescent experiencing anxiety and depression?

Management of Anxiety and Depression in Adolescents

For adolescents with comorbid anxiety and depression, begin with cognitive-behavioral therapy (CBT) or interpersonal psychotherapy for adolescents (IPT-A) as first-line treatment, reserving SSRIs (specifically fluoxetine) for moderate-to-severe cases or when psychotherapy alone is insufficient. 1, 2

Initial Assessment and Screening

All adolescents aged 12 years and older require annual universal screening for depression using validated self-report tools at health maintenance visits. 3, 2

• Use standardized screening instruments such as depression-specific scales to systematically identify both anxiety and depression concerns 2
• Assessment must include input from multiple sources: the adolescent, parents/guardians, and when appropriate, teachers or other caregivers 2
• Conduct systematic assessment using reliable depression scales, patient and caregiver interviews, and DSM-5 diagnostic criteria 3
• Screen for suicide risk, substance use, trauma history, family psychiatric history, and other comorbid psychiatric disorders 3

Immediate Safety Planning

Upon diagnosis, immediately establish a safety plan before initiating any treatment. 2

• Create a list of persons and/or services for the adolescent to contact, especially during the diagnosis and initial treatment period when safety concerns are highest 2
• Instruct families to remove lethal means from the home, particularly firearms 3
• Monitor for risk factors including sexual orientation, intellectual disability, and emerging suicidal ideation 3

Treatment Algorithm Based on Severity

Mild Depression with Anxiety

For mild symptoms, consider a brief period (2-4 weeks) of active support and monitoring with common-sense interventions before starting formal evidence-based treatment. 1

• Incorporate physical exercise, sleep hygiene, and adequate nutrition 1
• If symptoms persist or worsen, initiate psychotherapy (CBT or IPT-A) 1

Mild-to-Moderate Symptoms

Begin with psychotherapy as first-line treatment: CBT or IPT-A, consisting of 12-20 sessions. 1, 2

• CBT targets thoughts and behaviors through behavioral activation, cognitive restructuring, and improving assertiveness and problem-solving skills 2
• IPT-A addresses interpersonal problems that cause or exacerbate depression, focusing on improving interpersonal functioning and communication patterns 2
• Both CBT and IPT-A have demonstrated effectiveness in treating adolescent depression, with significant effects on reducing depression severity, suicidal ideation, and hopelessness 1
• Computerized CBT (CCBT) interventions have also shown positive results in primary care settings 1

Moderate-to-Severe Symptoms or Inadequate Response to Psychotherapy

Add SSRI medication to ongoing psychotherapy, with fluoxetine as the preferred first-line agent. 1, 2

Pharmacotherapy Guidelines

First-Line SSRI Selection

Fluoxetine is the only FDA-approved antidepressant for children and adolescents with depression and has the strongest evidence base. 1, 4

• Response rates: 47-69% for fluoxetine versus 33-57% for placebo 1, 2
• Start at lower doses than adult recommendations: 10 mg/day for adolescents, then increase to 20 mg/day after 2 weeks 4
• Dose range: 20-60 mg/day for OCD; maximum 80 mg/day 4
• Administer once daily, either morning or evening 4

Alternative SSRI Options

• Escitalopram is FDA-approved only for adolescents aged 12 years and older 2
• Sertraline can be considered: start at 25 mg/day for one week, then increase to 50 mg/day 5
• Dose range for sertraline: 50-200 mg/day, with changes no more frequently than weekly 5

Medications to Avoid as First-Line

Do not use duloxetine, venlafaxine, or paroxetine as first-line choices due to higher rates of intolerable side effects. 1

Critical Monitoring Requirements

Close monitoring is essential, especially during the first few months of treatment. 1

• Monitor for adverse events including nausea, headaches, and behavioral activation 1
• Be vigilant for emergence or worsening of suicidal thoughts and behaviors during early phases of antidepressant treatment 1
• Schedule regular contact after initiating treatment to review understanding, adherence, and adverse events 1
• Use systematic assessment of treatment effectiveness with standardized symptom rating scales 2

Discontinuation Protocol

All SSRIs must be slowly tapered when discontinued to avoid withdrawal effects. 1, 2

• Do not abruptly stop SSRIs 1
• Gradual dose reduction over several weeks is required 1

Practice Preparation and Community Linkages

Primary care clinicians should establish referral and collaboration resources with mental health specialists in the community before treating adolescent depression. 3

• Seek training in depression assessment, identification, diagnosis, and treatment if not previously trained 3
• Establish standing agreements with mental health practices regarding referral and exchange of clinical information 3
• Work with patients/families to establish individual education plans for school-based supports 3
• Connect to online or in-person support groups and advocacy organizations 3

Common Pitfalls to Avoid

• Do not delay treatment while waiting for specialty referral—provide initial management even when psychiatric services are limited 2
• Do not start antidepressants at adult doses; use lower recommended adolescent starting doses to reduce adverse event risk 1
• Do not conclude treatment is ineffective without adequate duration (at least 4-6 weeks at therapeutic dose) 1
• Do not ignore co-occurring disorders; integrated treatment produces better outcomes than treating single conditions 2
• Do not rely solely on screening tools for diagnosis; combine with clinical interviews and collateral information 3

Duration of Treatment

Continue treatment for several months beyond initial response. 4

• For depression: efficacy maintained for up to 38-44 weeks following acute treatment 4
• For OCD: continue for extended periods with periodic reassessment 4
• Dosage adjustments should maintain patients on the lowest effective dose 4

Special Considerations for Comorbid Anxiety and Depression

When both conditions are present, the same treatment approach applies, as CBT and SSRIs are effective for both anxiety and depression. 6, 7

• Online CBT programs with therapist support (8 modules, 8 telephone sessions) show promising results for comorbid cases, with 43.8% achieving remission from all disorders 7
• Anxiety symptoms may continue to improve during follow-up, while depressive symptoms may require ongoing intervention 6