CPAN Case of the Month – November 2023
Each month, PCPs call CPAN with a wide variety of mental health questions. Find out how CPAN helped a PCP during this consultation.
Patient: 14-year-old female
Reason for CPAN Consultation: To review criteria for Major Depression and the current evidence related to assessment and treatment
Explanation of the Case and Outcome of the Call:
A 14-year-old female in good health with irregular menses well regulated by oral contraceptives and spironolactone is continuing to struggle with depressive symptoms and sad mood lasting greater than 3 years. Family has begun therapy again after a pause and expresses frustration at the lack of response and treatment options. The PHQ-9 A score was 21, indicating a severe depression. The young person is positive for all depressive symptoms. They deny any suicidal or other dangerous thoughts or behaviors.
Child and Adolescent Psychiatrist Response:
The conversation focused on the criteria for Major Depression and the current evidence related to assessing and treating Major Depression. Reviewed their medical history and encouraged laboratory work-up focusing on Anemia, Vitamin D and Thyroid functioning as well as a beta HCG test. Next the discussion focused on the evidence for combined treatment with psychotherapy and psychotropic medications. Fluoxetine has the greatest amount of evidence for a modest effect size for moderate to severe depression that is not improved with therapy alone. The risks and benefits were reviewed including how to monitor for side effects and any potential emergence of suicidal ideations.
Primary Teaching Points:
- Standard of care for the treatment of major depressive disorder in children and adolescents includes a combination of both psychotherapy (preferably in the form of cognitive behavioral therapy) and medication management for youth with moderate to severe depression.
- Fluoxetine is FDA approved for the treatment of major depressive disorder in children and adolescents (ages 8+) and has the best available evidence for efficacy.
- Continued monitoring of symptom burden with the PHQ-9 A will help adherence to treatment and responsiveness to medication adjustments based on improvements or lack thereof. Encouraged the PCP to start low but not to wait too long if symptoms remain unchanged.
- Contact our team as frequently as needed to keep the treatment course moving towards remission.