Depression

Assessing the Teen for Major Depression

 

03/23/2011- When faced with a teenager who may have major depression key issues must be considered as part of the diagnostic process before even reviewing treatment options. Adolescents with possible major depression deserve a thoughtful and careful evaluation. As part of this assessment several points are worth highlighting.

 

03/23/2011- When faced with a teenager who may have major depression key issues must be considered as part of the diagnostic process before even reviewing treatment options. Adolescents with possible major depression deserve a thoughtful and careful evaluation. As part of this assessment several points are worth highlighting.

Safety First

The first pertains to a simple rule of thumb: “safety first.” Depressed youths may be at risk for self-injurious behavior. If dysphoric and irritable youths experience feelings of despair they may even consider harming others. For these reasons a thoughtful safety assessment is a prudent place to start. If an adolescent is potentially dangerous or suicidal his or her depression should not be treated in an outpatient setting.
Differential Diagnosis

Furthermore, the differential diagnosis of depression is extensive. It includes syndromal psychiatric conditions — including schizophrenia, schizoaffective disorder, bipolar illness, attention-deficit/hyperactivity disorder (ADHD), anxiety disorders, and substance abuse — as well as general medical illnesses such as thyroid disorders, mononucleosis, sleep disorders, and medication-related symptoms (eg, steroids, alpha-2 agonists). Youth with symptoms of major depression may actually have bipolarity. Mixed episodes and a depressive phase of a bipolar illness can both present with prominent depressive symptomatology.

Comorbidity

Finally, many teenagers with major depression also have comorbid conditions such as substance abuse disorders and ADHD. An appreciation of concomitant illnesses can help in formulating a treatment plan while recognizing which symptoms might not adequately respond to treatment for depression.
Approach to Therapy

Once one is reasonably confident that outpatient treatment is appropriate for a teenager’s major depressive episode, the question is how to begin. Before deciding on a specific course of action clinicians readily consider the putative risks and benefits associated with treatment. However, it is important to recall that major depression itself has risks. Major depression is associated with human suffering, impairments in social and scholastic functioning, intrafamilial difficulties, and even an increased risk for suicide. An appreciation of the perniciousness of this condition should be kept in mind when making therapeutic decisions.

Combination Therapy

Major depression can have such a substantive impact on a teen’s life, so I generally recommend that treatment consist of psychotherapy and pharmacotherapy in combination — rather than either one alone. If resistance to either intervention is substantive I accept that decision. However, I do try to identify, with the patient and his/her guardian, a time period after which — if the monotherapy is not effective — the addition of the currently eschewed intervention be reconsidered.

Psychotherapy

For combination therapy I generally recommend starting treatment with both an evidence-based form of psychotherapy and a US Food and Drug Administration (FDA)-approved pharmacotherapy. The best studied form of psychotherapy with evidence of efficacy in this population is cognitive-behavioral therapy (CBT). In addition, combination pharmacotherapy/psychotherapy studies have mostly focused on CBT as the form of psychotherapy. However, other forms of psychotherapy have evidence of efficacy such as interpersonal therapy. What is paramount is not necessarily what form of psychotherapy is applied but that the therapy is evidence based and provided by an experienced clinician.

Pharmacotherapy

The next issue is how to choose a medication. I generally think of FDA-approved medications as first-line agents because these compounds have the greatest body of evidence to support their use in this patient population. At present, only 2 agents are FDA approved for an indication of major depression in adolescents.

Fluoxetine. Fluoxetine is approved for use in children 8-18 years of age. For teenagers the recommended starting dose of fluoxetine is 10 mg/day or 20 mg/day. Generally I recommend a starting dosage of 10 mg/day for a week or so and then increase the dosage to 20 mg/day. With preadolescents I keep them on the 10-mg/day dosage longer (3-4 weeks) before raising the total daily dose of fluoxetine to 20 mg.

Escitalopram. Escitalopram, on the other hand, is approved for use in children 12 and years of age and older. The recommended starting dosage of escitalopram is 10 mg/day, but doses of 20 mg/day are FDA approved. I generally wait 2-3 weeks at a 10-mg dose level before I consider raising an escitalopram dosage to 20 mg/day in a teenager.

Black box warnings. Certainly, one can’t mention these agents, both of which are serotonin selective reuptake inhibitors (SSRIs) without mentioning their “black box” warnings. These warnings highlight that these agents are associated with increased risks for both suicidal behavior and suicidal thinking. Although the data from which this labeling was derived did not include any child who had a completed suicide, the phenomenon has enough data to take these risks seriously. Ultimately, the risk for untreated or ineffectually treated major depressive illness needs to be weighed against the safety considerations raised by these warnings.

Lack of Response

Data now suggest that if a teenager does not respond to treatment with an SSRI alone, adding CBT is probably a better course of action than simply changing medications. Conversely, when I have a patient who has not adequately responded to evidence-based psychotherapy I consider adding pharmacotherapy. However, for youths who are not responding fully to evidence-based psychotherapy it is less clear just how much added benefit that medication provides.

Finally, adolescent depression is a recurrent condition. Its detrimental consequences can persist into adulthood. For these reasons a treatment course for adolescents with depression should be seen from the perspective of managing a chronic condition for which long-term intervention is needed.

Author
Robert L. Findling, MD
   

Professor of Psychiatry and Pediatrics, Case Western Reserve University; Director, Child & Adolescent Psychiatry, University Hospitals Case Medical Center, Cleveland, Ohio

Disclosure: Robert L. Findling, MD, has disclosed the following relevant financial relationships:
Received grants for clinical research from: Abbott Laboratories; Addrenex Pharmaceuticals, Inc; AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Eli Lilly and Company; Forest Laboratories, Inc.; GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Neuropharm Group plc; Otsuka Pharmaceuticals Co., Ltd.; Pfizer Inc.; Rhodes Pharmaceuticals L.P.; Schering-Plough Corporation; Shire; Supernus Pharmaceuticals, Inc.; Wyeth Pharmaceuticals Inc.
Served as a consultant for: Abbott Laboratories; Addrenex Pharmaceuticals, Inc; AstraZeneca Pharmaceuticals LP; Biovail Corporation; Bristol-Myers Squibb Company; Eli Lilly and Company; Forest Laboratories, Inc.; GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; KemPharm, Inc.; Lundbeck Research USA, Inc.; Novartis Pharmaceuticals Corporation; Noven Pharmaceuticals, Inc.; Organon Pharmaceuticals USA Inc.; Otsuka Pharmaceutical Co., Ltd.; Pfizer Inc.; sanofi-aventis; Schering-Plough Corporation; Seaside Therapeutics; Sepracor Inc.; Shire; Solvay Pharmaceuticals, Inc.; Sunovion Pharmaceuticals Inc.; Supernus Pharmaceuticals, Inc.; Validus Pharmaceuticals LLC; Wyeth Pharmaceuticals Inc.
Served as a speaker or a member of a speakers bureau for: Bristol-Myers Squibb Company; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Shire
From Medscape Psychiatry & Mental Health
Treatment of Adolescent Depression

Robert L. Findling, MD

Medscape Psychiatry & Mental Health © 2011 WebMD, LLC

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