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Adolescent major depression: challenges to treatment.

C. first began to experience symptoms of depression at age 13. At that time, C. had become rejected by and isolated from his peers at school. He became increasingly sad, irritable, socially withdrawn, and discouraged with his schoolwork. A number of additional stressors occurred over the next two years, including a diagnosis of inflammatory bowel disease, the loss of his grandparents with whom he had a close relationship, a change of school, diagnoses of life-threatening illnesses in his father and uncle, confusion over his sexuality, and a break-up with his girlfriend. C.’s mood became increasingly unstable throughout this period. C. began individual psychotherapy for depressed mood in seventh grade, and continued with this treatment inconsistently until ninth grade. He was prescribed bupropion hydrochloride by his pediatrician during the eighth grade, after he changed schools and developed interpersonal struggles with his new teacher. The dosage was increased to 300 mg within three weeks. However, C. and his parents decided to stop the medication after he began to date a girl and appeared to be feeling better. Most recently, over the past several months, as reported by parents and the patient, C. has experienced depressed mood, hopelessness, worthlessness, guilt, low self-esteem, loss of interest in soccer and other sports, fatigue, impaired concentration, restlessness, and passive suicidal ideation. Bupropion was resumed approximately two months prior to C.’s initial evaluation due to worsening of mood. However, C. reported increased anxiety and lack of therapeutic response while he was taking the medication. One month prior to the evaluation, C. attempted to drown himself in the bathtub. He also acknowledged cutting his forearm a number of times in the past. C. denied that cutting himself was a suicidal act, but instead stated his intention was to “decrease emotional pain.” C. reported drinking alcohol to “get drunk” and self-medicate in the several months prior to the evaluation. He had smoked marijuana occasionally in the past; however, he had not done so within the past six months. C. denied suicidal intent or plan, and symptoms suggestive of mania or psychosis including racing thoughts, hearing voices, reduced need for sleep, grandiosity or delusional thinking. Past history, as reported by his parents, was notable that, as a young child, C had difficulty sustaining attention, was disorganized, forgetful, easily distracted, hyperactive (as if “driven by a motor”), and forgetful. In second grade, C. was diagnosed with attention-deficit/hyperactivity disorder (ADHD), combined type, and was prescribed methylphenidate. He subsequently developed motor tics, and the medication was discontinued.