The prevalence of Major Depression Disorder (MDD) in adolescents is 6%, with an additional 5-10% of teens presenting with sub-syndromal symptoms of depression. There is a 2:1 female: male ratio for MDD in adolescents. Teens frequently don’t necessarily present with the typical DSM criteria for MDD. Common depressive symptoms in adolescents include: irritability (as opposed to reporting sad mood), mood lability, being quick to get angry, low self-esteem, hopelessness, sleep disturbance, appetite disturbance, suicidal thoughts and attempts, isolation, loss of interest in activities they previously enjoyed, and impairment in academic and social functioning. Also associated with depressive conditions are non-suicidal self-injury behaviors that upwards of 1 in 4 high school youth report on surveys. Youth with depressive states may also report new-onset difficulties with sustaining attention and being academically motivated, which doesn’t fit well with a diagnosis of Attention Deficit Hyperactivity Disorder – inattentive subtype, because the symptoms were not present at a younger age. A major depressive episode can be triggered by a psychosocial stressor, but, if the symptoms last longer than 2 weeks, then it raises the suspicion of being more than an adjustment to a stressor. National data indicates that fewer than 50% of all teens with depressive illness receive any form of treatment, with minority and other disadvantaged groups receiving care at rates as low as 30%.
Depression is highly co-morbid with other psychiatric disorders, like anxiety disorders, substance abuse disorders and disruptive behavior disorders. If an adolescent is presenting with depressive symptoms, it is important to take a careful history of bipolar symptoms (including current and past manic, hypomanic or psychotic symptoms), family history of bipolar disorders, and history of medication-induced manic or hypomanic symptoms. Twenty percent of children and adolescents with depression go on to develop some degree of bipolar symptomatology as adults with symptoms of fluctuating moods and mood lability. Retrospective surveys also indicate that the typical timeline for adults with bipolar disorder indicated that they first experienced depressive symptoms starting in childhood or adolescence.
In 2014, the American Academy of Pediatrics updated their well child visits for adolescents (ages 11-17 years) to include screening for depression. The PHQ-2 (PHQ 2) has good sensitivity and specificity for detecting major depression. These properties, coupled with the brief nature of the instrument, make this tool promising as a first step for screening for adolescent depression in primary care. The more detailed PHQ-9 Adolescent ( PHQ 9 Adolescent ) can be administered for positive findings on the PHQ-2.
Adolescents will sometimes turn to drugs, like alcohol or marijuana or cigarettes/e-cigarettes, to self-medicate. If they are using on a regular basis, the use can be contributing to their depressive symptoms, and psycho-education about that interaction will be important. Ongoing regular drug use can also limit the efficacy of a medication treatment for depression. Therefore it is important to talk with teens about limiting their drug use if they are interested in a medication intervention.
In terms of general treatment guidelines, consider therapy alone for mild-moderate cases of MDD and consider combination therapy and medication treatment for moderate-severe cases of MDD, particularly if there is a significant impairment from their symptoms. Fluoxetine is the medication that has been studied the most for MDD in children and adolescents, but the other SSRIs, like citalopram, escitalopram and sertraline, can also be utilized. Other options to consider are bupropion and mirtazapine. The antidepressants to consider avoiding include: paroxetine and venlafaxine (because of their short half-lives, there is a higher risk of side effects and discontinuation symptoms with inconsistent use) and duloxetine (because of limited data in children and adolescents).
It is important to conduct a slower titration, starting with ½ the usual starting dose, to minimize the risk of side effects including akathisia (internal restlessness), behavioral activation and increased anxiety. So, for example, if considering fluoxetine, a starting dose of 10mg q day would be appropriate with a plan to increase to 20mg after 2 weeks if tolerated and needed. Advancing the dose higher may be warranted but should be done after 3-4 weeks on a standard therapeutic dose and with care and with close follow up as to efficacy and to assess for potential side effects. It is important to discuss the length of time it can take for a patient to see a full positive result, so that the teen and family is realistic with their expectations. It is also important to carefully discuss with the teen and family the FDA black box warning about the increase in risk of spontaneous reporting of suicidal thinking and have close monitoring (follow-up in 1-2 weeks either in person or by phone), particularly when medication is started or when the dose is being increased.
Helpful resources for families:
- https://www.aacap.org/AACAP/Families_and_Youth/Resource_Centers/Depression_Resource_Center/Depression_Resource_Center.aspx
- https://www.appi.org/dulcan