A 14-year-old girl comes to the office accompanied by her mother for an annual examination. The patient's medical problems include acne, for which she takes clindamycin. When seen alone for examination, she is shy and quiet. The patient says everything is "going okay." She does not have a boyfriend and is not sexually active. When asked about drug and alcohol use, she says, "No, but I have tried alcohol and marijuana a few times at parties." Physical examination is normal other than mild acne, which has improved since her last visit. Following the examination, the physician informs the mother that everything is fine, renews the patient's clindamycin prescription, and asks if she has any questions. With the daughter present, the mother replies, "I remember what it's like to be a teenager, but she is really impossible to deal with now. I can't get her up on time in the morning because she stays up late on her computer. She no longer wants to spend time with the family. In the morning, she refuses to eat breakfast and then sleeps during the entire drive to school. I worry because her school friends use drugs. I think they are a bad influence and now her grades are falling. I don't know how she will get into a decent college. We warned her that she wouldn't be allowed to go on the family vacation if she doesn't improve her grades, but she doesn't seem to care." The physician speaks with the patient privately and begins by asking her more about school. She says, "I'm really upset about my grades and I feel guilty because my parents have been saving up to send me to college. I just space out when the teacher is lecturing. When it comes to tests, I can't remember anything I have read." When asked about her friends and substance use, she says, "Some of my friends smoke marijuana, but I don't even go out with them. I prefer to go straight home after school, stay in my room, and sleep or listen to music. The last time I tried marijuana was at a party 4 months ago." When asked about her sleep, the patient says, "It's hard to get up in the morning when I feel so tired. I quit the volleyball team because the coach was mean and I couldn't get up early for practice." She has not been dieting or vomiting and says, "I skip meals because I'm just not that interested in food." The patient avoids spending time with her family because "my mom just gets on my nerves and she is always critical. I really don't want to go on vacation with my family. I just want to be left alone." Which of the following is the most appropriate next step in management of this patient?

Question

A 14-year-old girl comes to the office accompanied by her mother for an annual examination.  The patient's medical problems include acne, for which she takes clindamycin.  When seen alone for examination, she is shy and quiet.  The patient says everything is "going okay."  She does not have a boyfriend and is not sexually active.  When asked about drug and alcohol use, she says, "No, but I have tried alcohol and marijuana a few times at parties."  Physical examination is normal other than mild acne, which has improved since her last visit.  Following the examination, the physician informs the mother that everything is fine, renews the patient's clindamycin prescription, and asks if she has any questions.  With the daughter present, the mother replies, "I remember what it's like to be a teenager, but she is really impossible to deal with now.  I can't get her up on time in the morning because she stays up late on her computer.  She no longer wants to spend time with the family.  In the morning, she refuses to eat breakfast and then sleeps during the entire drive to school.  I worry because her school friends use drugs.  I think they are a bad influence and now her grades are falling.  I don't know how she will get into a decent college.  We warned her that she wouldn't be allowed to go on the family vacation if she doesn't improve her grades, but she doesn't seem to care." The physician speaks with the patient privately and begins by asking her more about school.  She says, "I'm really upset about my grades and I feel guilty because my parents have been saving up to send me to college.  I just space out when the teacher is lecturing.  When it comes to tests, I can't remember anything I have read."  When asked about her friends and substance use, she says, "Some of my friends smoke marijuana, but I don't even go out with them.  I prefer to go straight home after school, stay in my room, and sleep or listen to music.  The last time I tried marijuana was at a party 4 months ago."  When asked about her sleep, the patient says, "It's hard to get up in the morning when I feel so tired.  I quit the volleyball team because the coach was mean and I couldn't get up early for practice."  She has not been dieting or vomiting and says, "I skip meals because I'm just not that interested in food."  The patient avoids spending time with her family because "my mom just gets on my nerves and she is always critical.  I really don't want to go on vacation with my family.  I just want to be left alone."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Additional information on this patient obtained privately suggests a diagnosis of major depression (irritable mood, anhedonia, social isolation, low energy, sleep and appetite changes, and poor concentration). Adolescents with depression may have feelings of annoyance and irritability rather than sadness. Associated functional impairments include disturbances in school functioning and in relationships with parents and peers. Other symptoms of major depression include psychomotor agitation or retardation, thoughts of worthlessness or inappropriate guilt, and recurrent thoughts of death or suicide. A safety assessment must be performed for any patient exhibiting symptoms of depression. The most appropriate next step is assessing the patient for suicidal ideation, intent, and plan. (Choice A) Checking thyroid function is an important part of the workup for depression, but assessment of safety takes precedence. (Choices B, C, and D) Further assessment of this patient's depression and discussion of treatment options with her and her parents should precede treatment. If the diagnosis is confirmed, individual and family psychotherapy can be considered. Fluoxetine is an appropriate agent for treating moderate to severe unipolar major depression in an adolescent and is preferably combined with psychotherapy. Educational objective: Depressed children and adolescents may display irritable rather than depressed mood. Initial evaluation of all children and adolescents with depression should include careful suicide risk assessment. References: Adolescent depression: clinical features and therapeutic strategies. (http://www.ncbi.nlm.nih.gov/pubmed/23771545) Guidelines for adolescent depression in primary care (GLAD-PC): I. Identification, assessment, and initial management. (http://www.ncbi.nlm.nih.gov/pubmed/17974723) Pediatric depression: an evidence-based update on treatment interventions. (http://www.ncbi.nlm.nih.gov/pubmed/23881712)

A 14-Year-Old Girl Comes to the Office Accompanied by Her