She is fifteen and has been taking sertraline for three weeks. Her mother asks if we can increase the dose, since the first dose didn’t work quickly enough. I look at her medication list, which is already longer than mine was at twice her age. I find myself doing something I rarely do during a seven-minute visit: I pause.
I do not doubt the value of antidepressants. I have seen these medications help adolescents recover from very dark times. Still, I have started to sense that our field has quietly crossed a line we never really discussed. When I finally looked at the data, the numbers were more troubling than I expected.
A recent analysis of Germany’s largest statutory health insurer tracked psychotropic prescribing in adolescents aged 12 to 17 from 2015 to 2023. Among girls, sertraline prescriptions rose 482 percent. Escitalopram rose 194 percent. On the antipsychotic side, a class we are supposed to reserve, aripiprazole use in girls climbed 110 percent and quetiapine 59 percent, pushing overall antipsychotic prescribing in girls up 26 percent even as it fell in boys.
What caught my attention was not just the size of the increase, but the authors’ interpretation. They wrote that the amount and nature of the change exceeded what more diagnoses alone could explain. This, they suggested, points to earlier drug intervention and more off-label prescribing. In other words, we are not just finding more illness. We are prescribing sooner, and sometimes for reasons the medication was not originally approved for.
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This trend is not unique to Germany. In the United States, monthly antidepressant prescriptions for adolescents and young adults rose 66 percent between 2016 and 2022. The increase sped up after the pandemic began, especially in one group. Among girls aged 12 to 17, the dispensing rate rose 129.6 percent faster after March 2020 than before. For adolescent boys, the rate actually dropped.
Despite different health systems and continents, the same pattern appears: Teenage girls are most affected.
I want to be fair about prescribing, because most of it is reasonable and some of it is clearly helpful. Selective serotonin reuptake inhibitors (SSRIs) are still the main medication for treating depression and anxiety in adolescents, and fluoxetine and escitalopram have Food and Drug Administration (FDA) approval for pediatric depression. The American Academy of Pediatrics, responding to a national youth mental health crisis, has specifically asked primary care providers to treat mild-to-moderate depression and anxiety, including with medication when needed.
That is the context people often mention, and they are right. For years, the main problem was undertreatment. Much of the increase comes from breaking down barriers. There is more telehealth, less stigma, and more primary care clinicians willing to start an SSRI instead of referring to a child psychiatrist who may not be nearby. That is progress, and I will not deny it.
But access and appropriateness are not the same, and the data cannot separate them. An upward trend in prescriptions looks the same whether it means a girl finally received needed treatment, or a girl was given a diagnosis and medication for normal adolescent struggles because it was the quickest option in a short visit. The German authors noticed that prescribing was outpacing diagnosis and described it as a possible shift in prescribing habits, not just a change in disease.
Every pediatric antidepressant comes with an FDA black-box warning for suicidal thoughts and behaviors in youth. This warning is not meant to scare us, but to require close monitoring during the first weeks and after any dose change. A meta-analysis found a small but real increase in suicidal thoughts or attempts compared to placebo, about 0.7 percentage points. Side effects like restlessness, insomnia, and disinhibition are more common in adolescents than adults, which is why guidelines recommend starting with a low dose and increasing slowly.
Now consider the setting where most prescribing happens: short visits, busy clinicians, and families who see a higher dose as progress. The close monitoring required by the black-box warning is often the first thing to be dropped when schedules are full. We have taken on the easy part of the intervention, writing the prescription, but often skip the harder part.
This does not mean we should automatically prescribe less. Untreated adolescent depression can be deadly. My point is that a 482 percent increase deserves the same careful review we would give any other procedure with such a rise, but that has not happened. We should be able to say how much of this increase is due to meeting real needs and how much is due to medicalizing normal distress. Right now, we cannot, because no one is measuring the difference.
So I return to the fifteen-year-old and her mother. We do not increase the dose today. Instead, we talk about what three weeks of treatment can and cannot show us, about therapy, and about what we are really treating. This conversation takes more time than the visit allows. That, I think, is the real issue. Writing the prescription was the easy part. It always is.
Timothy Lesaca is a psychiatrist in private practice at New Directions Mental Health in Pittsburgh, Pennsylvania, with more than forty years of experience treating children, adolescents, and adults across outpatient, inpatient, and community mental health settings. He has published in peer-reviewed and professional venues including the Patient Experience Journal, Psychiatric Times, the Allegheny County Medical Society Bulletin, and other clinical journals, with work addressing topics such as open-access scheduling, Landau-Kleffner syndrome, physician suicide, and the dynamics of contemporary medical practice. His recent writing examines issues of identity, ethical complexity, and patient–clinician relationships in modern health care. Additional information about his clinical practice and professional work is available on his website, timothylesacamd.com. His professional profile also appears on his ResearchGate profile, where further publications and details may be found.
