Jacqueline Russell is a 17-year-old female who comes in the clinic with complaints of generalized fatigue which started two months ago. Accompanying symptoms include anxiety, anhedonia, irritability, and problems concentrating. Major life changes include recent breakup with her boyfriend and pressure in school while expected by her parents to have a scholarship. She stated that she gets enough sleep but still feel tired upon waking up. Key findings include being overweight, easily cries, unintentional 25-30 weight gain last year, history of marijuana use, Acanthosis Nigricans, and striae on abdomen and buttocks. She denies taking any medications other than Ibuprofen for menstrual cramps. She occasionally drinks beer. The patient skips breakfast but eats high calorie foods like pizza and French fries several times per week.
The patient denies any suicidal ideations but stated that she wants to “disappear” and not deal with her situation. Risk factors include family history of diabetes II and obesity. Lab findings are negative for anemia, negative urine drug screen, normal T4, TSH levels, and CBC.
BMI 28.8 (overweight)
Patient is reluctant to make eye contact Crying
Pressure from being a senior at school
Mother made her come, pressure from parents Per patient gets enough sleep but wakes up tired Unintentional 25-30 weight gain last year Stretch marks
Marijuana use Hx with old boyfriend Breakup with boyfriend
Skips breakfast, eats high calorie foods like pizza and french fries several times per week Constantly snack at night to keep going
Anhedonia in school and leisure activities Upset, irritable, angry, frustrated, and cries daily
Feels irritable and annoyed a lot by family and parents, they blame on her periods. Problems concentrating daily
Wants to disappear and not deal with situation Occasionally drinks beer
Acanthosis Nigricans at nape Striae on abdomen and buttocks
Takes Ibuprofen for menstrual cramps, pain is not bad per patient.
Tried marijuana last year with old boyfriend, denies any other recreational drugs Used to baby sit for a family neighbor
Major Depressive Disorder – Symptoms similar to Jacqueline are depressed mood, irritability, markedly diminished interest and pleasure in usual activities, and symptoms that lasts at least two weeks. Common symptoms of depression also include change of appetite (25-30 lbs. weight gain), low energy and fatigue, and difficulty concentrating. MDD is diagnosed if there have been at least two weeks of depression with at least four accompanying symptoms of depression.
General Anxiety Disorder – The most common comorbidity with depression is anxiety disorder. Major symptoms similar to Jacqueline are unexplained fatigue, irritability, difficulty concentrating,
Type II Diabetes Mellitus Hypothyroidism
O-2 months ago L-generalized
D-Constant per mother C-
A-Pressure from school as a senior
A-Gets enough sleep but still wakes up tired R-?
S-Don’t feel like doing anything
Consider cognitive behavioral therapy and psychoeducation in collaboration with a pediatric psychiatrist. Antidepressant medications may be considered first-line treatment for moderate-to- severe depression or depression that has not responded to an adequate trial of psychotherapy
Family interventions and involvement in cognitive-behavior therapy
Fluoxetine (Prozac) 10 mg PO daily. Fluoxetine has the strongest evidence for use in pediatric depression (Mullen, 2018). May take at night if feelings of drowsiness occur during the day.
Have a healthy balanced diet that includes fruits, vegetables, whole grains, fat free or low-fat milk, lean meats, eggs, and seafood.
Engage in a 60 minute or more of moderate to vigorous intensity physical activity each day. Activities may include aerobics, running, jumping, and muscle-strengthening (climbing, push- ups).
Get enough quality sleep. The Centers for Disease and Control and Prevention (CDC) recommends 8-10 hour per 24 hours of sleep for teens 13-18 years of age (CDC, 2021)
Children’s Depression Inventory (CDI) scale or PHQ-9 modified scale for teens Type II Diabetes Mellitus – HbA1c level, Random fasting glucose Hypothyroidism – Thyroid stimulating hormone (TSH) and free T4
Anemia – Complete blood counts (CBC)
Urinalysis – Rule out infection since it mimics depression symptoms in female children and adolescents (Dunphy et al., 2015). Screen for sexually transmitted infection.
Urine Pregnancy Test – Since the patient is at childbearing age and taking Fluoxetine may increase the risk of cardiovascular malformations in infants (Gao et al., 2017).
Vitamin D level – Vitamin D deficiency has been associated with fatigue and treatment with vitamin D supplement significantly improved symptoms in a double-blind placebo-controlled trial (Nowak et al., 2016). Therefore, it is crucial that this is assessed to identify the need for vitamin supplementation.
Drug Screening – Childhood depression increases the risk of developing substance-related disorders (Groenman et al., 2017). Since the patient had a prior history of Marijuana use, it is important to test for other illicit drug use.
Lipid Panel – Due to the family history of hypertension and obesity. Furthermore, the patient’s sedentary lifestyle with consumption of foods high in fat increases the risk of cardiovascular disease.
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Educate the patient and parent that it takes four to six weeks of starting an antidepressant medication to see its maximum response and doses can be adjusted to improve response every two to four weeks as long as significant side effects are absent. Explain that elevated energy can occur due to the medications. Therefore, it is crucial that parents report symptoms that merit immediate evaluation such as decreased impulse control, marked elevation of mood, acting out, fearlessness, and risk taking. Report immediately if the child expresses suicidal ideations or behaviors. Ensure that the child has no access to weapons or medications or any other means of self-harm and have constant supervision during treatment.
Explain to the patient to follow mediation regimen as instructed and never abruptly discontinue as it may result in adverse effects such as nausea, sweating, dysphoric mood, irritability, agitation, dizziness, sensory disturbances, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures.
Avoid alcohol while taking antidepressants. There is correlation of alcohol dependence and major depression thus two conditions may have a causal effect with each disorder increasing the risk of developing the other (Kuria et al., 2012).
Consult pediatric mental health therapist for psychotherapy, cognitive-behavior therapy, and patient-family counseling.
Refer to community support groups for children and families experiencing depression
Follow up by phone within three days of starting pharmacotherapy and have the patient come back in the clinic weekly for four weeks to evaluate response to therapy. Once stable, may have maintenance visits every three months. If no improvement within two months of starting SSRI, reassess the need for hospitalization if in immediate danger.