What is the next best step for a 17-year-old university student with symptoms of anxiety and depression, including insomnia, tachycardia, decreased appetite, and loose bowel motions, who has not responded to escitalopram (citalopram) 10 mg orally daily after one week and has undergone cognitive behavioural therapy (CBT) twice, with no current thoughts of self-harm?

Continue Escitalopram and Intensify CBT with Close Monitoring

The next best step is to continue escitalopram 10 mg daily and increase the frequency of cognitive behavioral therapy sessions, as one week is insufficient time to assess antidepressant response, which requires 4-8 weeks at therapeutic doses. 1

Why Continuing Current Treatment is Appropriate

Inadequate Trial Duration

• Antidepressants require at least 8 weeks at optimal dosage before concluding treatment is ineffective. 1
• This patient has only been on escitalopram for one week, which is far too early to expect meaningful symptom improvement. 1
• The American Academy of Pediatrics guidelines emphasize that premature discontinuation before completing an adequate 8-week trial leads to false conclusions about treatment failure. 1

Escitalopram is Evidence-Based for This Age Group

• Escitalopram is FDA-approved for adolescents aged 12 years and older with depression and anxiety disorders. 1, 2
• Clinical trials demonstrate escitalopram superiority to placebo (64% vs 53% response rate) in adolescents. 1
• Escitalopram is effective for both anxiety and depressive symptoms, making it ideal for this patient's mixed presentation of racing heart, insomnia, decreased appetite, and loose bowel motions. 3, 2

CBT Requires More Sessions

• The patient has only attended two CBT sessions, but evidence-based protocols require 12-16 weekly sessions to achieve meaningful symptomatic and functional improvement. 4
• CBT alone showed only a 43.2% response rate in adolescents, which was not significantly different from placebo (34.8%), emphasizing the need for adequate session frequency and duration. 5

Immediate Management Steps

Increase Monitoring Frequency

• Schedule weekly in-person follow-up visits for the first 4-8 weeks to evaluate depressive symptoms, suicide risk, adverse effects, treatment adherence, and environmental stressors. 1
• The FDA black box warning emphasizes increased risk of suicidal thinking during early antidepressant treatment, making close monitoring essential despite this patient currently denying self-harm thoughts. 1
• Use standardized symptom rating scales (PHQ-9 for depression, GAD-7 for anxiety) at each visit to objectively track treatment response. 5, 4

Intensify CBT Sessions

• Increase CBT frequency to weekly sessions and ensure the therapist is implementing core evidence-based components including psychoeducation about the thought-feeling-behavior connection, behavioral activation, cognitive restructuring, and relaxation techniques. 4
• Address the specific adjustment stressors this patient faces: difficulty making friends, missing lectures, and separation from home. 4
• Incorporate graduated exposure techniques for the anxiety symptoms (racing heart when studying), teaching deep breathing and progressive muscle relaxation. 4

Address Environmental Factors

• Explore whether poor sleep, social isolation, and academic stress are being adequately addressed through behavioral interventions and campus support services. 1
• Provide psychoeducation to both the patient and parents about the expected timeline for medication response and the importance of treatment adherence. 4

When to Escalate Treatment

Indicators for Dose Increase (After 4-6 Weeks)

• If symptoms show no improvement after 4-6 weeks at 10 mg daily, increase escitalopram to 20 mg daily, which is the effective dose for most adolescents. 1
• Further dose increases of 10-20 mg increments can be made at weekly intervals if needed, with a maximum dose of 60 mg daily. 1

Indicators for Switching or Adding Therapy

• If no improvement after 6-8 weeks despite adequate treatment, explore poor adherence, comorbid disorders (substance use, undiagnosed ADHD), or ongoing conflicts/abuse before changing the treatment plan. 1
• For partial response to maximum tolerated SSRI dosage after 8 weeks, consider switching to fluoxetine, which has the strongest evidence base in adolescents. 1

Indicators for Psychiatric Consultation

• Immediate consultation with psychiatry is necessary if the patient develops active suicidal ideation with plan or intent, psychotic symptoms, or severe functional impairment requiring hospitalization. 1
• Consultation should also be considered if symptoms worsen despite treatment optimization or if complicating factors emerge such as substance abuse. 5

Common Pitfalls to Avoid

Premature Treatment Changes

• Changing or discontinuing escitalopram after only one week is the most common error, as this prevents the patient from receiving an adequate therapeutic trial. 1
• Starting at adult doses rather than the current 10 mg dose would increase the risk of adverse events and deliberate self-harm. 1

Inadequate Follow-Up

• Failing to schedule weekly monitoring visits in the first 4-8 weeks misses critical opportunities to detect emerging suicidality, adverse effects (nausea, headaches, behavioral activation), or treatment non-adherence. 1
• Not using standardized rating scales makes it difficult to objectively assess whether treatment is working. 5, 4

Ignoring Adjustment Issues

• The patient's symptoms began two months ago when starting university, suggesting significant adjustment disorder components that require targeted CBT interventions for social skills, problem-solving, and stress management. 4
• Failing to address the social isolation and academic difficulties through behavioral interventions will undermine medication response regardless of the pharmacologic choice. 1