Medication Treatment Algorithm for Adolescent Depression in Primary Care 4/16/24

Adolescent depression is a significant mental health concern, with potential long-term implications if left untreated. While psychotherapy remains a cornerstone of treatment, medication can be an essential component for moderate to severe cases or when psychotherapy alone is insufficient.

This medication treatment algorithm outlines evidence-based pharmacological interventions for adolescent depression, incorporating safety considerations, efficacy, and potential adverse effects. The algorithm can serve as a guide and should be individualized based on clinical judgment, patient preferences, and specific clinical circumstances. Regular monitoring and reassessment are essential throughout the treatment process.

Step 1: Initial Assessment

  • Comprehensive Evaluation: Conduct a thorough assessment, including psychiatric history, symptom severity, medical history, family history, and suicidality risk. Consider differential diagnosis and co-morbidities.
  • Psychotherapy: Initiate or continue evidence-based psychotherapy, such as cognitive-behavioral therapy (CBT) or interpersonal therapy (IPT). Inform psychotherapist of planned psychopharmacologic treatment and maintain ongoing collaborative dialogue as warranted
  • Education and Informed Consent: Educate the patient and their family about the potential benefits, risks, and side effects of medication treatment. Obtain informed consent.

Step 2: First-Line Pharmacotherapy

  • Selective Serotonin Reuptake Inhibitors (SSRIs):
    • Fluoxetine: Start with a low dose (10 mg/day) and titrate gradually to therapeutic range (20-60 mg/day).
    • Escitalopram: Initiate at 5-10 mg/day, titrate up to 10-20 mg/day.
    • Sertraline: Begin with 25-50 mg/day, titrate up to 50-200 mg/day.
  • Monitoring:
    • Close monitoring for therapeutic response and adverse effects, especially during the first 4-6 weeks and following future dose increases, if instituted.
    • Assess for emergence or worsening of suicidal ideation, agitation, or behavioral activation.

Step 3: Treatment Response Assessment

  • Response Evaluation: Evaluate response to SSRI treatment after 4-6 weeks.
  • Adjustment: If partial response or inadequate response, consider:
    • Increasing SSRI dose, gradually at q 2-4 week intervals.
    • Switching to another SSRI.
    • Adding psychotherapy or non-pharmacological interventions.

Step 4: Second-Line Pharmacotherapy

  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):
    • Venlafaxine: Initiate at 37.5 mg/day, titrate up to 75-225 mg/day.
    • Duloxetine: Start with 30 mg/day, titrate up to 60-120 mg/day.
  • Bupropion: Consider in cases with atypical depression symptoms or when SSRIs or SNRIs are ineffective or not tolerated.
    • Begin with 75 mg/day, titrate up to 150-300 mg/day.
  • Monitoring:
    • Continuously monitor for therapeutic response and adverse effects.
    • Assess for potential drug interactions, especially with other psychotropic medications.

Step 5: Consultation and Collaboration

  • Collaboration: Maintain open communication with the patient, their family, and involved healthcare professionals throughout treatment.
  • Consultation: Consider consultation with a child and adolescent psychiatrist for complex cases, treatment-resistant depression, or significant comorbidities.

Step 6: Continuation and Maintenance

  • Continuation Phase: Once remission is achieved, continue the effective medication at the same dose for at least 6-12 months to prevent relapse.
  • Maintenance Phase: For recurrent depression or chronic conditions, consider long-term maintenance treatment with medication and/or psychotherapy.

Safety Considerations:

  • Suicidality Risk: Monitor closely for emergence or worsening of suicidal ideation, especially during the initial weeks of treatment.
  • Serotonin Syndrome: Educate about symptoms and signs, especially if combining SSRIs or SNRIs with other serotonergic medications.
  • Drug Interactions: Be cautious with concomitant use of other medications metabolized by cytochrome P450 enzymes. Avoid monoamine oxidase inhibitors (MAOIs).
  • Monitoring Parameters: Regularly assess for efficacy, adverse effects, vital signs, and growth parameters in adolescents.


Shawn Singh Sidhu, M.D., DFAPA, DFAACAP

​Medical Co-Director, Vista Hill Foundation


  • American Academy of Child and Adolescent Psychiatry (AACAP). (2019). Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.
  • Cheung, A. H., & Emslie, G. J. (2015). Treatment-resistant depression in adolescents. Pediatric Drugs, 17(6), 383-392.
  • National Institute for Health and Care Excellence (NICE). (2019). Depression in children and young people: identification and management (Clinical guideline [CG) 28).
  • Zhou, X., Hetrick, S. E., Cuijpers, P., Qin, B., Barth, J., Whittington, C. J., … & Xie, P. (2015). Comparative efficacy and acceptability of psychotherapies for depression in children and adolescents: A systematic review and network meta-analysis. World Psychiatry, 14(2), 207-222.
  • Baldwin, D. S., & Montgomery, S. A. (2005). Serotonin selective reuptake inhibitors. Journal of Psychopharmacology, 19(2_suppl), 4-6.
  • Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., … & Fava, M. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. The American Journal of Psychiatry, 163(11), 1905-1917.
  • Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., … & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366.
  • Taylor, D., Paton, C., & Kapur, S. (2019). The Maudsley prescribing guidelines in psychiatry. John Wiley & Sons.
  • Nutt, D. J. (2008). Relationship of neurotransmitters to the symptoms of major depressive disorder. The Journal of Clinical Psychiatry, 69, 4-7.
Posted in Blog and tagged , , , .