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Background
The patient is a fifteen year old Caucasian male. He is in the ninth grade at a public
school. Due to a drop in his academic performance and deteriorating mood his guidance
counselor is seeking information on an effective treatment plan to provide to the parents of said
patient. The patient has reported feelings of increased sadness, fatigue, and thoughts of suicide
over the last month. He has withdrawn himself from social groups and activities stating that he
is just no longer interested in that stuff anymore. This is a symptom called anhedonia, which
means the inability to feel joy or happiness. Because these symptoms have lasted longer than two
weeks and the patient has reported no recreational drug or alcohol use it fits the criteria of
depressive disorder as defined in Axis 1 of the DSM IV.
Options
There are many treatment plans available for adolescents with depressive disorder and
depending on the patient some are more effective than others. The main methods are
pharmacotherapy and psychotherapy.
Pharmacotherapy is the treatment of depression through prescription antidepressant
drugs. The drugs most commonly used are second generation antidepressants called SSRI’s
(selective serotonin reuptake inhibitors) these effect the neurotransmitters in the brain. The
medication Fluoxetine (Prozac) is the only SSRI approved by the FDA to have more positive
effects in adolescents than the negative effects caused by side effects. These drugs are often
accompanied by Abilify which enhances the effects of the antidepressant but has proven side
effects of causing an increase in suicidal thoughts in adolescents.
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Psychotherapy or more recently called interpersonal psychotherapy is a method of
treatment that consists of one-on-one counseling of the patient by a Mental Health professional.
These sessions regularly occur once or twice a week or in severe cases such as hospitalization
due to suicidal or homicidal thoughts, they can occur daily. The goal of these sessions is to
reduce depressive symptoms as well as improving social functioning and problem-solving skills.
Comparison
Pharmacotherapy treatment
Pharmacotherapy is based on the prescription of antidepressant drugs to relieve
depressive symptoms in the patient. Through researching scholarly journals on the topic, and
interviewing mental Health Professionals I have learned that the most commonly prescribed
antidepressants are second generation antidepressants called SSRI’s (serotonin reuptake
inhibitors.) SSRI’s effect the neurotransmitters in the brain.
There are several SSRI’s on the market today but the one that the FDA has approved for
the treatment of depression in children and adolescents is Prozac 10-20mg daily dosage. Prozac
has been found to be the safest SSRI due to the side effects such as suicidal thoughts and
ideations to be outweighed by the benefits of the drug. Other symptoms are anxiety, drowsiness,
dizziness, dry mouth and flu like symptoms.
These second generation antidepressants are often prescribed in accompaniment with
Abilify, which is a drug proven to improve the effects of SSRI’s. At the mental Health Hospital I
work at, all of the adolescents that are prescribed antidepressants take Abilify as well. It was
stated in studies and by the Mental health Professionals at the Hospital that suicidal thoughts and
ideations are side effects of Abilify. Patients taking an antidepressant or antidepressant
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accompanied by Abilify should be monitored closely to insure that suicidal symptoms do not
develop or worsen.
In this chart from a review of second generation antidepressants from
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=antidep&part=A48 you will see that
fluoxetine which is Prozac was the most effective versus placebo effects and against other SSRI
medications in March et al.’s trial.
Table 11
.
Interventions, Numbers of Patients, and Quality Ratings of Studies in Children and
Adolescents with Major Depressive Disorder
Author, Year
Interventions
N
Results
Systematic Review
Whittington Citalopram vs. Placebo (SR)
2,145 Only fluoxetine had favorable
96
et al., 2004
Fluoxetine vs. Placebo
risk-benefit profile
Paroxetine vs. Placebo Sertraline
vs. Placebo Venlafaxine vs.
Placebo
SSRIs versus Placebo
Wagner et al., Citalopram vs. Placebo
174 Significantly greater efficacy
200497
for citalopram
March et al., Fluoxetine plus CBT vs.
439 Greater improvement on the
98
2004
Fluxoetine vs. CBT vs. placebo
CDRS-R for fluoxetine plus
CBT compared to fluoxetine
alone, CBT alone, or placebo
Keller et al., Paroxetine vs. Imipramine vs.
275 No differences
200199
Placebo
Wagner et al., Sertraline vs. Placebo
376 Significantly greater efficacy
100
2003
for sertraline
SNRIs versus placebo
Mandoki et Venlafaxine vs. Placebo
40 No differences
101
al., 1997
Quality
Rating
Fair
Fair
Good
Fair
Fair
Fair
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It is not doubted that SSRI medications work to relieve depressive symptoms however it
has been stated by Wolf and Hopko in their critical review of different treatments for depression
that Psychotherapy has become a second hand resource to Pharmacotherapy due to lack of
availability and the cost-effectiveness of antidepressants.
In the same article it also states that antidepressants are often prescribed by primary care
physicians and not mental health professionals. Primary care physicians, although well educated,
are not required to annually further their education on mental health treatments and therefore
may not require frequent patient evaluations or accompaniment of psychotherapy.
Psychotherapy Treatment
The treatment method of psychotherapy involves the one-on-one counseling of a patient
by a Mental Health Professional that focuses on current problems. There are several different
versions of psychotherapy such as: Cognitive therapy, cognitive-behavioral therapy, Problemsolving therapy and Interpersonal therapy.
Throughout all of these methods of psychotherapy the patient is taught skills related to
problem-solving and coping that alleviates problems interfering with psychosocial functioning.
This treatment has been proven to be effective with pharmacological methods but also has
several beneficial features over alternative treatments for example there are no side effects. The
skills learned in psychotherapy such as problem-solving has a success rate that shows less of a
chance of relapse over pharmacotherapy.
With this treatment method in a twelve week period there are decreased depressive
symptoms, improved social functioning, and improved interpersonal problem-solving skills. The
limited availability of psychotherapy due to reasons involving health insurance often puts
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pharmacotherapy without any therapeutic intervention as the first line of treatment. Many
patients who receive such care have stated their lack of satisfaction with it. Once the medication
has ceased the prevalence of the symptoms returning is greater in patients who have received
none or limited therapeutic intervention.
In this chart above retrieved from a study on the differential responses of psychotherapy versus
pharmacotherapy, when childhood trauma is involved, psychotherapy proves to be a more
effective form of treatment. Also, how else would one come to the conclusion that the depressive
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symptoms are caused by childhood trauma without therapeutic intervention. In many cases
traumatic childhood events are subconsciously buried as the minds way of coping with the grief.
Although the cost of psychotherapy is greater, and insurance companies are less willing
to cover the expenses, it is necessary to the recovery of the patient. If the symptoms are treated
with just medication and not resolved through therapy the outcome could result in hospitalization
due to preexisting suicidal thoughts, accompanied by medications with side effects including
suicidal thoughts. These treatments must be closely evaluated by professionals and as progress
occurs the dosages may need to be altered. If the patient is simply just seeing his primary care
physician for the medication, such close observations cannot be offered.
Psychotherapy accompanied by medication is a form of treatment just as effective as
psychotherapy alone but again psychotherapy should be used as the front line because it resolves
the problems more effectively.
Conclusion
Throughout this recommendation report I have discussed two treatment methods for the
patient in question. The first method is pharmacotherapy. This method is more cost-effective and
because of health insurance reasons, is unfortunately the first line of treatment by primary Care
Physicians. Prozac an SSRI is the safest form of antidepressants for adolescents with depression
but noted side effects are suicidal thoughts and ideations. Prozac is often accompanied by Abilify
to enhance the effectiveness however Abilify has the same noted warnings.
Comparing pharmacotherapy to psychotherapy, psychotherapy has been proven to be just
as or more effective in certain areas of treatment and serves with zero side effects. Psychotherapy
not only relieves depressive symptoms, but it has better long-term effectiveness by teaching the
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patient different skills to cope with their emotions as opposed to just covering them up with
medications.
Recommendation
My recommendation for the adolescent male who fits the DSM IV TR criteria for
depressive disorder is psychotherapy. At least one 60 minute assessment session with a Mental
Health professional followed by several 30-60 minute sessions until the depressive symptoms are
relieved and better interpersonal and problem-solving skills are developed to help the patient
cope with his emotions. If, after 10 to 12 sessions the patient feels his symptoms are not relieving
or the suicidal tendencies reoccur I then recommend altering the patient’s treatment plan to
include antidepressant medication but to maintain psychotherapy treatment as well.
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Works Cited
Sommers-Flanagan, John and Campbell, Duncan G. Psychotherapy and (or) Medications for
Depression in Youth? An evidence-based Review with Recommendations for Treatment.
Government Employee 2008, Online 2009. Retrieved November 2009 from PsychInfo.
Wolf, Nicole J., Hopko, Derek R. Psychosocial and Pharmacological Interventions for Depressed
Adults in Primary Care: A Critical Review. Clinical Psychology Review 28, 131-161,
2008. Retrieved November 2009 from Psych Info.
http://www.pnas.org/content/100/24/14293/F1.large.jpg
Laura Mufson, PhD; Myrna M. Weissman, PhD; Donna Moreau, MD; Robin Garfinkel, PhD.
Efficacy of Interpersonal Psychotherapy for Depressed Adolescents . Archives of General
Psychiatry 56, 6 June 2009. Retrieved December 2009.
Drug Class review of Second Generation Antidepressants. Oregon Health and Science University
2006. Retrieved from
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=antidep&part=A48 December
2009.