PUPC Conference Coverage

Evidence-Based Strategies Show Strong Outcomes in Treating Adolescent Mental Health Post-Pandemic

Kate Young

Key Highlights:

  • Mental health conditions in adolescents are highly prevalent, with COVID-19 significantly worsening outcomes.
  • Universal screening for depression and anxiety in primary care (ages 12-18) is strongly recommended and supported by validated tools.
  • First-line treatment includes psychotherapy, with fluoxetine as the most evidence-based pharmacologic treatment for adolescent depression.
  • Combination therapy (psychotherapy + pharmacotherapy) is superior for both depression and anxiety in achieving faster and more complete remission.

Mental health conditions in adolescents are highly prevalent and worsening, particularly in the wake of the COVID-19 pandemic, according to Laurie Garner, PA-C, and James Luccarelli, MD, DPhil, who discussed the urgency of addressing adolescent mental health during their session at the 2025 Practical Updates in Primary Care virtual conference.

Adolescent mental health is shaped by both neurodevelopmental processes and environmental stressors. Adolescents, whose brains are still developing through the mid-20s, rely more heavily on the amygdala before the prefrontal cortex matures, contributing to impulsive and emotional behaviors. Anxiety and depression are the most commonly observed, often co-occurring and leading to significant impairment in functioning. The evidence, according to Ms Garner and Dr Luccarelli, indicates strong response rates to available treatments, particularly when both psychotherapy and pharmacotherapy are utilized in combination. For depression, fluoxetine stands out as the most effective first-line medication, and for anxiety, escitalopram and duloxetine are FDA-approved and well-supported. Most cases can be successfully managed in the outpatient primary care setting, with remission as the goal.

The pandemic introduced social isolation, disrupted routines, school closures, and financial strain on families, all of which created a “perfect storm” for deteriorating mental health. Communities of color and under-resourced families faced disproportionate challenges. As a result, in 2021, multiple national pediatric organizations declared a national state of emergency in adolescent mental health.

To evaluate these issues, clinicians in primary care implemented universal screening strategies. The U.S. Preventive Services Task Force recommends routine depression screening for ages 12–18, and anxiety screening for ages 8 to 18, using tools such as the PHQ-2, PHQ-9, SCARED, and the Social Phobia Inventory. Screening is now often conducted even during problem-based visits. Clinicians also probe red flags such as suicidal ideation, substance use, self-harm, and family stress. Adolescents presenting with persistent symptoms for over two weeks and demonstrable functional impairment are evaluated for intervention. Differential diagnoses include medication effects, chronic illness, and nutritional deficiencies.

Findings from two major NIMH-funded trials—the Treatment for Adolescents with Depression Study and Child/Adolescent Anxiety Multimodal Study—highlight that fluoxetine and sertraline (used in the study though not FDA-approved for anxiety) are effective in combination with cognitive behavior therapy (CBT) for both depression and anxiety. CBT alone shows delayed effectiveness, but combination therapy leads to faster remission. Adherence, however, remains a challenge, with high dropout rates from psychotherapy and common issues with medication compliance. Fluoxetine is the default choice for depression in youth, with dosing adjusted by age. Escitalopram and duloxetine are used for generalized anxiety disorder. The number needed to treat for antidepressants is 10, while the number needed to harm is 143—demonstrating a favorable benefit-to-risk ratio despite the FDA black box warning.

Despite these advances, access to mental health care remains limited due to provider shortages, cost, and stigma. Only half of adolescents who need mental health care receive it. Adolescents from marginalized groups often face greater barriers, further complicating care delivery. Psychotherapy access varies by region, and many providers have moved to cash-based models, further straining access.

“These conditions are common, treatable, and when we use evidence-based screening and treatment practices, we can expect strong outcomes—even in primary care settings,” Dr Lucerelli concluded.

References:
Garner L, Luccarelli. Digging deeper series: Adolescent mental health. Practical Updates in Primary Care. July 16-18, 2025. https://www.hmpglobalevents.com/pupc