Adolescents with depression that fails to respond to a selective serotonin reuptake inhibitor show more improvement with a switch to cognitive-behavioral therapy and another medication regimen than with a switch to a medication regimen alone, according to a multicenter study.
The Treatment of SSRI-Resistant Depression in Adolescents trial, funded by the National Institute of Mental Health, is the first to evaluate teens with the chronic symptoms and significant suicidal ideation that are typically seen in community practice but are excluded from most studies.
The 334 study subjects had failed to respond to at least 8 weeks of an initial SSRI (40 mg of fluoxetine or the equivalent of another agent), wrote Dr. David Brent of the University of Pittsburgh and colleagues.
The average age of the subjects was 16 years, and 82% were white. Most had moderately severe symptoms, with a median duration of 17 months. About 59% showed clinically significant suicidal ideation, and half had at least one comorbid disorder.
The subjects were randomly assigned to receive a different SSRI alone, venlafaxine (Effexor) alone, a different SSRI plus cognitive-behavioral therapy (CBT), or venlafaxine plus CBT. The CBT focused on “cognitive restructuring and behavior activation, emotion regulation, social skills, and problem solving” and included parent-child sessions as well.
After 12 weeks, 55% of those receiving CBT showed an adequate clinical response, compared with 41% of those who had not received it. There were no significant differences in response between a second SSRI or venlafaxine, nor were there differences in responses to the various SSRIs used, the authors said (JAMA 2008;299:901–13).
“The slightly higher rate of cardiovascular effects associated with venlafaxine and the relatively modest treatment effects in adolescent depression … support the choice of another SSRI over venlafaxine as a second-line antidepressant,” they added.
A significant difference was found in the response to CBT according to which study site administered it, a finding that will be further explored in a future report. However, the overall positive effect of CBT was robust in sensitivity analyses, even after controlling for site factors. The study limitations include the absence of ethnic diversity in the patients. Dr. Brent reported no financial disclosures.
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