Depression — Medication Management Recommendations — Clinical Pathway: Outpatient Behavioral Health and Primary Care

Depression Clinical Pathway — Outpatient Behavioral Health and Primary Care

Medication Management Recommendations

Consent for Medication

Prior to initiating antidepressant medication, the clinician should use mutual decision making and review the benefits and risks of the medication, as well as alternatives to the medication, and discuss patient/family questions and concerns. The clinician should document that this discussion occurred and whether the patient/caregiver chose to proceed with the treatment.

  • To the extent possible, the plan shall be made with the cooperation, understanding and consent of the person in treatment
  • The discussion should include the FDA recommendation for prescribers to alert caregivers about the need to closely monitor patients for clinical worsening, suicidality, or unusual changes in behavior, especially during initiation of drug therapy or following dose adjustments.
  • Caregivers should also be made aware of the risks of not treating depression

Medication Initiation

  • The following are FDA approved medications for treatment of MDD in children and adolescents. Do not use with MAOIs (monamine oxidase inhibitors).
  • Start with lower doses in younger children.

For additional information on medications, please refer to formulary  .

SSRI Dosing and Adverse Effects

  Medication Starting Dose Increments Effective Dose Maximum Dose Common Adverse Effects
First Line Fluoxetine 5-10 mg po daily 10-20 mg 20 mg 60 mg Headaches, GI upset, insomnia, agitation, anxiety
Second Line Escitalopram (first-line: 12 and over) 2.5-5 mg po daily 5 mg 10-20 mg 20 mg Headaches, GI upset, insomnia

Medication Considerations

Mild major depression
Moderate and severe major depression
  • Children and adolescents with Moderate and Severe Major Depression will generally require a combination of treatment with antidepressants and psychotherapy

Medication Management

For additional information regarding medication management, refer to CHAMP Depression Evaluation and Treatment Protocol. View CHAMP

Acute phase of treatment

FDA-approved medications for the treatment of moderate to severe depression in children and adolescents is limited to fluoxetine (age 8-17) and escitalopram (age 12-17).

  • Start either fluoxetine or escitalopram at lower than typical starting dose for adults to avoid side effects and improve adherence to treatment.
  • The dose should be titrated based upon effectiveness and tolerance.
  • Target doses in children and adolescents are similar to those used for adult patients.
  • During the acute phase of treatment, prescribers should work in collaboration with the family and other members of the mental health treatment team to closely monitor for response, tolerability, and safety.
  • Although individual patient factors will determine the frequency of follow-up*, youth who are newly diagnosed with depression and started on an antidepressant should ideally be evaluated by either the prescriber, therapist, or another member of the treatment team:
    • Once a week for the first 4 weeks
    • Every two weeks for the next 4 weeks
    • And then monthly or per clinical judgment
      • * An alternative follow-up schedule is proposed, providers should document their clinical reasoning and family members should be encouraged to call 1) immediately with any concerns and 2) at scheduled intervals to provide updates between follow-up appointments.
  • Once a plan of care is initiated, a follow-up rating scale should be used to assess clinical response to treatment. It is recommended to use the same rating scale (BDI-II, CDI-2, PHQ-9, PHQ-A, DSM-5 self-rated level 2- depression- child age 11-17, CDRS-R or MADRS) as the initial evaluation and to repeat the rating scale monthly. Functioning should also be reassessed using the Clinical Global Assessment of Functioning Scale (CGAS) or The Columbia Impairment Scale (CIS), Youth and Parent monthly during acute treatment and every 3 months during continuation and maintenance treatment.
  • If a clinical response has not been obtained in patients who have been treated with adequate and tolerable doses for at least 4 weeks, the dose may be increased.
  • Patients who are showing minimal or no response after 8 weeks of treatment are likely to need alternative treatments such as augmentation with psychotherapy or a change in medication (see non-responders below).
  • The goal of acute treatment should be remission of symptoms by 12 weeks of antidepressant treatment

Continuation phase of treatment

  • For all patients who have achieved adequate clinical response or remission of symptoms, treatment should be continued for another 6 to 12 months to avoid relapse.
  • During continuation treatment, patients are typically seen at least monthly or based on clinical judgment. Follow-up sessions should continue to foster medication adherence, optimize the dose, and evaluate for the presence of side effects.
  • During continuation treatment, symptoms and functioning should be reassessed every 3 months.

Maintenance phase of treatment

  • Once the child has achieved recovery the clinician and family should decide whether maintenance treatment is indicated to prevent recurrence of depression.
  • The maintenance phase may last for an additional 12 months or longer, with monthly to quarterly visits depending on clinical judgment and patient factors.
  • During maintenance treatment, symptoms and functioning should be reassessed every 3 months.

Treatment of Non-Responders or Resistant Depression