Depression is a common mental health problem among teens that results in constant feelings of sadness and a lack of interest in everyday activities. There is an increasing prevalence of depression among teens, with almost 50% of teens have experienced depressive disorder once in their lifetime (Beirão et al., 2020). Due to the recurrent nature of depression among adolescents and its impact on academic performance, relationships, and functional deficiency, it is essential for healthcare professionals to make a timely and correct diagnosis of the condition. This paper explains the causes, symptoms, diagnosis, treatment, and considerations for depressive disorder among adolescents.
Causes and Symptoms of Depressive Disorder in Adolescents
The causes and risk factors of depressive disorders are multifactorial ranging from environmental, psychosocial, and neurological factors. Serra (2017) states that exposure to adversity during childhood, peer pressure, and identity struggles can cause depressive disorders (Serra, 2017). Influence by the media and gender customs are likely to intensify the difference between teens’ aspirations and the realities of their present lives. Depression among teens can also be caused by family economic status and the impacts of peer relationships (Beirão et al., 2020). For example, forms of violence, including sexual violence and bullying, parental mistreatments, and severe socio-economic conditions, are known determinants of mental health.
Many adolescents could be at more significant risk of depression because of their living conditions, stigma, different forms of discrimination, and inadequate support systems (Serra, 2017). Such teenagers could be living in humanitarian and delicate environments and those suffering from chronic diseases. Other groups of adolescents at risk of depression include parents, pregnant teenagers, orphans, adolescents from minority groups surviving discrimination, and those in forced marriages. Exposure to such a socio-cultural and physical environment impairs the person’s neurological resistance to stressors, thus causing depression.
Many adults may not identify the symptoms of depression in adolescents as the condition might manifest in different forms as those in adults. The first notable signs would be difficulties in learning, relationships, and reduced life enjoyment (Serra, 2017). Adolescents suffering from depression might show signs such as depressed mood, hopelessness, lack of interest in routine activities, withdrawal, constant cries, lack of sleep, and irritability (Beirão et al., 2020). In addition, some depressed adolescents show signs of tiredness, lack of concentration, and talking or having suicidal thoughts.
Diagnosis of Depressive Disorder in Adolescents
Adolescents are considered vulnerable since they are still physically, academically, and emotionally developing and thus have low health literacy. Furthermore, they are economically empowered to make autonomous decisions for seeking healthcare services. It is recommended that healthcare professionals should carry out a targeted screening of adolescents from high-risk groups. Questionnaires can come in handy since they are quick and economical to administer. Studies have shown that the PHQ-2 screening for depression among adults can also work well for teenagers (Beirão et al., 2020). Also, caregivers can use the 25-item strength and difficulties questionnaire (SDQ) to offer extra screening for ADHD and other symptoms of disruptive behavior (Beirão et al., 2020). In case of uncertainty about the reliability of responses generated from PHQ-2 and SDQ items, a short mood and feelings questionnaire and children’s depression inventory can be applied.
A full clinical assessment is recommended for individuals with scores above the cutoff points. The evaluation includes a sensitive and empathetic inquiry on the different symptoms, duration, severity of the depressive disorder, and other related impairments in an interview with teenagers (Serra, 2017). The interviews should not be carried out in the presence of the accompanying adults. However, all information offered by the accompanying adults is crucial as there is more excellent reliability and validity in diagnoses using information from different sources (Beirão et al., 2020). Also, it is crucial to assess adolescents’ risk of suicide and how they function at school or home.
Medication/Treatment Options
Pharmacotherapy is applied when psychotherapy is not available or in a situation where it cannot be applied. The Food and Drug Administration (FDA) has only approved using fluoxetine and escitalopram in treating teen depression (Bouattour, 2018). Because of its efficacy, fluoxetine is mainly used as the first line of pharmacotherapy treatment in adolescents. Fluoxetine has side effects such as diarrhea, headaches, vomiting, and anxiety (Beirão et al., 2020). They may also cause abdominal pains, restlessness, and notable variations in sleep patterns. A mental health specialist should carefully evaluate patients under escitalopram treatment as it may lead to prolonged QT intervals likely to cause arrhythmia.
Research has shown that the use of antidepressant drugs is linked to increased suicidal thoughts in some young adults under 25 years, especially at the beginning of the therapy (Beirão et al., 2020). Healthcare professionals should therefore carry out risk vs. benefit analysis of the therapy and ensure that adolescents on these drugs are closely monitored for suicidal signs. Providers should also consider the severity of depressive disorders, comorbidities, and polypharmacy during medication. The presence of other comorbidities and polypharmacy would dictate that the provider consider drug interactions and contraindications.
Medications Considerations
Fluoxetine is known to interact with different drugs such as MAOIs, antipsychotics, and antidepressants and may lead to deadly complications, including abnormal heart rhythms, seizures, or bleeding. When used with eliglustat, for example, fluoxetine can raise eliglustat levels that impact the metabolism of enzyme CYP2D6 (Steele & Roberts, 2020). If fluoxetine is administered with a CYP2D6 inhibitor, the eliglustat dose should be reduced from 84mg BID to mg once a day (Steele & Roberts, 2020). Also, both fluoxetine and linezolid can raise the level of serotonin. Linezolid might raise the level of serotonin due to MAO-A inhibition. In case a patient has to be treated with linezolid, it is recommended that the serotonergic drug should be discontinued immediately CNS toxicity should be monitored (Steele & Roberts, 2020). Escitalopram also interacts with drugs such as leuprolide, pimozide, thioridazine, and ziprasidone. A mixture of escitalopram and these medications increases QTc levels. In addition, escitalopram and selegiline raise the level of serotonin (Steele & Roberts, 2020). The discontinuation and initiation between the two drugs should happen after at least 14 days.
Why is it Important to Monitor Fluoxetine and Escitalopram?
Research has shown that patients with comorbid general illnesses are more likely to experience major depressive episodes. Depressed patients struggling with other medical conditions are at higher risk for the chronic course of depressive disorder (Steele & Roberts, 2020). Some of the comorbid to look out for when prescribing antidepressants include cancer, heart diseases, and HIV/AIDS (Steele & Roberts, 2020). These illnesses might lower antidepressants’ response rate or lengthen the recovery time, as they could be a significant source of stress.
It is essential for healthcare professionals to check the progress of their patients through regular visits to ensure the prescriptions are working as expected. Unwanted effects can be determined through blood tests. Patients on escitalopram doses must be monitored regularly for behavior or mood change (Steele & Roberts, 2020). Fluoxetine may make some adolescents agitated, easily irritable, or show different unusual characteristics (Steele & Roberts, 2020). Antidepressant medication may also result in suicidal thoughts or put some on the road to further depression.
Special Considerations when Prescribing Escitalopram and Fluoxetine
The treatment of depression encompasses professional and ethical essentials of doing ‘what is right by providing appropriate healthcare services. For example, for healthcare professionals working in states mandating reporting of alleged domestic violence, the mental health specialist is obliged to comply with the legal requirements, their judgment of the situation notwithstanding (Rogol, 2020). Ethically, mental health specialists must adhere to autonomy and confidentiality principles. They have to respect their patient’s rights to confidentiality by not revealing the details of the patient’s treatment sessions or other details of their condition they wish to keep private.
Social determinants of health, including discrimination based on race, sexual orientation, and economic status, have been linked to mental health outcomes in many world countries (Alegría et al., 2018). Given the significant association between these factors and health outcomes, healthcare professionals are encouraged to implement and support multilevel intervention strategies to eradicate such inequalities, especially for young people (Alegría et al., 2018). They can support programs that promote interactions and sensitization through social media, educational institutions, and religious organizations to improve behavioral health outcomes. Lastly, symptomatic manifestation and treatment of depression may vary in various cultural groups. For example, depressed youth from economically disadvantaged families or those struggling with drug and substance abuse may face stigma and are not likely to seek medication. Healthcare professionals can mitigate this by partnering with community-based organizations working to offer support to such populations. They can offer depression-related education and the required medication support for recovery.
Follow-Up: Where Can the Affected Youth Find Help?
Many organizations and websites can offer the necessary support and information. One such organization is the National Alliance on Mental Illness (NAMI). NAMI is a popular organization working at the grassroots to improve the lives of those suffering from mental health illnesses (Singh et al., 2019). They have implemented different programs to create awareness of mental health and assist community members in managing the condition. Another organization is the Anxiety and Depression Association of America (ADAA), which works to assist individuals having depression. ADAA of support in terms of education and treatment resources. One can also find a mental health therapist in ADAA’s directory.
Prescription Examples
Fluoxetine is a once-a-day drug that can be taken in the morning or evening and administered at 20mg every day at the beginning of the treatment. Fluoxetine is available in different forms, including oral solution (20mg or 5ml), 10/20mg tablets, 10/20/40mg capsules, and 90mg delayed-release capsules (Steele & Roberts, 2020). The drug can be efficacious at a 5mg dose, and considering its side effects; the drug should be given in small doses. To reduce the side effects, the drug can be given in 10mg dose instead of 20mg for patients with poorly tolerated side effects (Steele & Roberts, 2020). However, 20mg and 40mg of the drug are adequate for most individuals.
Example 1: Major Depressive Disorder
Patient’s name: John Rowland
Date of Birth: 12/9/2003
Medication and strength: fluoxetine (Prozac) 20mg
Amount, route, and frequency: 20mg PO qDay
Refills: Weekly
Provider’s signature XXXX Date 23/9/2022
Example 2: Resistant Depression
Patient’s name: Diana Brighton
Date of Birth: 23/6/2002
Medication and strength: fluoxetine (Prozac) 20mg plus olanzapine 5mg
Amount, route and frequency: 20mg fluoxetine + 5mg
olanzapine PO qHS
Refills: Weekly
Provider’s signature XXXX Date 23/9/2022
Example 3: Bipolar Associated Depression
Patient’s name: Brian Joseph
Date of Birth: 13/1/2001
Medication and strength: fluoxetine (Prozac) 20mg plus olanzapine 5mg
Amount, route, and frequency: 20mg fluoxetine + 5mg olanzapine PO qHS
Refills: Weekly
Provider’s signature XXXX Date 23/9/2022
In conclusion, diagnosing depression in adolescents is a complex process, while the treatment requires individualized and oriented medication. Therefore, it is essential to make early identification and initiate prompt treatment. For the prognosis of depression patients, referrals to mental health specialists are recommended. The depression diagnosis is a complicated process because depression can manifest itself in different forms, and there are actual diagnostic tests to identify the condition. However, numerous differential diagnoses should be carried out to offer an accurate course of medication. Both psychotherapy and pharmacotherapy can be helpful in the management of the condition.
References
Alegría, M., NeMoyer, A., Falgàs Bagué, I., Wang, Y., & Alvarez, K. (2018). Social Determinants of Mental Health: Where and where we need to go. Current Psychiatry Reports, 20(11). https://doi.org/10.1007/s11920-018-0969-9
Beirão, D., Monte, H., Amaral, M., Longras, A., Matos, C., & Villas-Boas, F. (2020). Depression in adolescence: A Review. Middle East Current Psychiatry, 27(1). https://doi.org/10.1186/s43045-020-00050-z
Bouattour, W. (2018). Anxiety and depression in adolescence. https://doi.org/10.26226/morressier.5a6ef3ead462b80290b57d84
Serra, G. (2017). Factors associated with depression severity in adolescence. https://doi.org/10.26226/morressier.588f064fd462b8028d891e45
Singh, S., Zaki, R. A., & Farid, N. D. (2019). A systematic review of Depression literacy: Knowledge, help‐seeking and stigmatizing attitudes among adolescents. Journal of Adolescence, 74(1), 154–172. https://doi.org/10.1016/j.adolescence.2019.06.004
Steele, R. G., & Roberts, M. C. (2020). Handbook of evidence-based therapies for children and adolescents: Bridging science and practice. Springer.
Rogol, A. M. (2020). Ethical issues in the evaluation and treatment of depression. FOCUS, 18(2), 201–204. https://doi.org/10.1176/appi.focus.20200006
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