A 15-year-old girl is brought to the office by her mother, who is concerned about her moodiness and poor grades. For the past 3 months, the patient has been uncharacteristically irritable and withdrawn. The mother says, "She snaps at everyone for no reason and then slams the door to hide in her room." The patient was previously active socially with several close friends and was an A student but now has stopped attending after-school activities, has no friends, and struggles to maintain a C average. On weekends, she spends most of her time sleeping. When seen alone, the patient tearfully describes herself as a failure and says, "I'm stupid and ugly." She can no longer concentrate to complete her homework or school projects and failed a recent math test. She has no suicidal ideation or medical conditions. Physical examination is normal apart from weight gain of 2 kg (4.4 lb) since her annual checkup 3 months previously. On mental status examination, the patient is fidgety, makes poor eye contact, and picks at her fingernails. Laboratory values, including TSH, are within normal range, and urine drug screen is negative. The patient and her mother ask if medication is a treatment option. In addition to psychotherapy, which of the following is the most appropriate recommendation?
This patient's 3-month history of irritable mood, hypersomnia, impaired concentration, decreased interest in social activities, and feelings of worthlessness is consistent with major depressive disorder (MDD). Pediatric depression often presents with symptoms of irritability rather than depressed mood. The patient's symptoms warrant treatment because they have resulted in a marked change from her baseline as well as significant academic and social impairment. Treatment options for pediatric depression include psychotherapy, pharmacotherapy, or a combination of these.
Pharmacotherapy is effective for pediatric depression, and evidence shows that selective serotonin reuptake inhibitors (SSRIs) are most effective and generally well tolerated. Among the SSRIs, fluoxetine is considered the medication of choice based on several meta-analyses. Children and adolescents should be closely monitored for increasing suicidal thoughts or behaviors during antidepressant treatment because a slightly increased risk of suicidality has been demonstrated in a small group of patients.
(Choice A) The second-generation antipsychotic aripiprazole is not a first-line treatment for pediatric depression. It is primarily used in the treatment of psychotic and bipolar disorders.
(Choice B) Although bupropion has less potential to cause weight gain, this medication is not considered a first-line treatment for pediatric depression because it has not been well studied in this population. It can be considered for patients who do not respond to an SSRI.
(Choice D) Methylphenidate is a first-line treatment for attention deficit hyperactivity disorder (ADHD). This patient's impaired concentration and fidgetiness on mental status examination are manifestations of her MDD, not primary symptoms of ADHD, which would have manifested prior to age 12.
(Choice E) SSRIs have demonstrated efficacy in pediatric depression.
(Choice F) Unlike fluoxetine, which has good evidence and is approved for use in pediatric depression, venlafaxine lacks sufficient evidence from clinical trials to recommend its use as initial treatment in the pediatric age group. It can be considered for SSRI nonresponders.
Educational objective:
Pediatric depression can present with symptoms of irritability rather than depressed mood. Treatment options include psychotherapy and/or pharmacotherapy. Fluoxetine is the drug of choice.