What medication can be initiated for an 18-year-old female patient presenting with depression, anxiety, and suicidal ideation without a plan?

From the Guidelines

For an 18-year-old female with depression, anxiety, and passive suicidal thoughts, I would recommend starting with an SSRI such as fluoxetine (Prozac) 10mg daily for one week, then increasing to 20mg daily. This medication should be taken in the morning due to potential activation effects. Fluoxetine is a good first-line choice because it has FDA approval for adolescents and young adults with depression, has anxiolytic properties, and has a relatively favorable side effect profile 1. The patient should be monitored closely during the first 4 weeks of treatment due to the small increased risk of suicidal ideation when starting antidepressants in young adults, with a pooled absolute rate of 1% for suicidal ideation in youths treated with an antidepressant and 0.2% for youths treated with a placebo 1. Common side effects include nausea, headache, insomnia, and sexual dysfunction. Full therapeutic effect may take 4-6 weeks. In addition to medication, the patient should be referred for psychotherapy, preferably cognitive behavioral therapy, which has been shown to reduce suicidal ideation and behavior 1. The patient should have regular follow-up appointments to assess response and monitor for worsening of suicidal thoughts. If the patient's suicidal ideation worsens or she develops a plan, immediate psychiatric evaluation is necessary. It's also important to note that other medications such as lithium and clozapine may be considered in certain cases, but they are not typically first-line treatments for depression and anxiety in young adults 1. Overall, the goal of treatment is to reduce symptoms of depression and anxiety, improve quality of life, and minimize the risk of suicidal behavior.

From the FDA Drug Label

Sertraline is a prescription medicine used to treat depression It is important to talk with your healthcare provider about the risks of treating depression and also the risks of not treating it. PAXIL is a prescription medicine used to treat depression It is important to talk with your healthcare provider about the risks of treating depression and also the risks of not treating it.

Medication Options:

• Sertraline 2 can be used to treat depression.
• Paroxetine 3 can be used to treat depression.

Key Considerations:

• The patient is 18 years old and experiencing depression, anxiety, and suicidal thoughts with no plan to act on them.
• Both sertraline and paroxetine have warnings about increased suicidal thoughts or actions in some children, teenagers, or young adults within the first few months of treatment or when the dose is changed.
• It is essential to monitor the patient's symptoms and adjust treatment as needed.
• The patient should be informed about the potential risks and benefits of treatment.

Recommendation: Start the patient on sertraline 2 or paroxetine 3 under close supervision, with regular follow-up visits to monitor symptoms and adjust treatment as needed.

From the Research

Medication Options for Depressed Adolescents

The patient, an 18-year-old female, is experiencing depression, anxiety, and suicidal thoughts with no plan to act on them. Considering her symptoms, the following medication options can be explored:

• Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has been shown to be effective in treating depression in adolescents 4, 5, 6, 7.
• Combination therapy of fluoxetine and cognitive behavioral therapy (CBT) has been found to be superior to fluoxetine alone in reducing depressive symptoms and suicidal thoughts in adolescents 4, 6, 8, 7.

Efficacy of Combination Therapy

Studies have consistently shown that combination therapy of SSRI and CBT is more effective than monotherapy in treating depression and anxiety in adolescents:

• A meta-analysis found that fluoxetine plus CBT achieved higher response rates, lower incidence of adverse reactions, and lower proportion of suicide or self-injury compared to fluoxetine alone 6.
• Another study found that SSRI+CBT significantly decreased symptoms by week 4 and continued to improve at week 8 and 12, with the fastest response seen in younger patients with milder baseline symptoms 8.

Considerations for Treatment

When considering treatment options for the patient, the following factors should be taken into account:

• The patient's age and severity of symptoms, as younger patients with milder symptoms may respond faster to combination therapy 8.
• The potential benefits and risks of each treatment option, including the risk of suicidal thoughts and behavior, which has been found to decrease with fluoxetine and CBT combination therapy 4, 5, 6.