Treat depressed teens with medication &lt;i&gt;and&lt;/i&gt; psychotherapy

,; Smith, Sandy; ,

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Treat depressed teens with medication and psychotherapy

J Fam Pract. 2008 November;57(11):735-739, 739a

By

Benjamin W. Van Voorhees, MD, MPH

Sandy Smith, PhD

Bernard Ewigman, MD, MSP

Combining SSRIs and cognitive behavioral therapy boosts recovery rates

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References

1. Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299:901-913.

2. March JS, Silva S, Petrycki S, et al. The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. Arch Gen Psychiatry. 2007;64:1132-1143.

3. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292:807-820.

4. Kessler RC, Walters EE. Epidemiology of DSM-IIIR major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depress Anxiety. 1998;7:3-14.

5. Rushton JL, Clark SJ, Freed GL. Pediatrician and family physician prescription of selective serotonin reuptake inhibitors. Pediatrics. 2000;105:E82.

6. Hankin BL. Adolescent depression: description, causes, and interventions. Epilepsy Behav. 2006;8:102-114.

7. Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE . Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120:e1313-e1326.

8. Birmaher B , Brent DA, Benson RS. Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1998;37:1234-1238.

9. Yates P, Kramer T, Garralda E . Depressive symptoms amongst adolescent primary care attenders. Levels and associations. Soc Psychiatry Psychiatr Epidemiol. 2004;39:588-594.

10. Rushton JL, Forcier M , Schectman RM . Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. J Am Acad Child Adolesc Psychiatry. 2002;41:199-205.

11. Johnson JG, Harris ES, Spitzer RL , Williams JB. The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolesc Health. 2002;30:196-204.

12. Compton SN, March JS, Brent D, Albano AM, Weersing R , Curry J. Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. J Am Acad Child Adolesc Psychiatry. 2004;43:930-959.

13. Asarnow JR, Jaycox L H, Anderson M . Depression among youth in primary care models for delivering mental health services. Child Adolesc Psychiatr Clin N Am. 2002;11:477-497, viii.

14. Wisdom JP, Clarke GN, Green CA. What teens want: barriers to seeking care for depression. Adm Policy Ment Health. 2006;33:133-145.

15. Zuckerbrot R A, Cheung AH, Jensen PS, Stein RE , Laraque D. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007;120:e1299-e1312.

16. Van Voorhees B W, Fogel J, Houston TK, Cooper LA, Wang NY, Ford DE. Beliefs and attitudes associated with the intention to not accept the diagnosis of depression among young adults. Ann Fam Med. 2005;3:38-46.

17. Clever SL, Ford DE, Rubenstein LV , et al. Primary care patients’ involvement in decision-making is associated with improvement in depression. Med Care. 2006;44:398-405.

18. Lacasse JR. Consumer advertising of psychiatric medications biases the public against nonpharmacological treatment. Ethical Hum Psychol Psychiatry. 2005;7:175-179.

19. Van Voorhees B W, Cooper L A, Rost KM, et al. Primary care patients with depression are less accepting of treatment than those seen by mental health specialists. J Gen Intern Med. 2003;18:991-1000.

20. Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ. 2004;328:265.

21. Anderson L , Lewis G, Araya R, et al. Self-help books for depression: how can practitioners and patients make the right choice? Br J Gen Pract. 2005;55:387-392.

22. Van Voorhees B W, Vanderploegbooth K, Fogel J, et al. Integrative Internet-based depression prevention for adolescents: a randomized clinical trial in primary care for vulnerability and protective factors. J Can Acad Child Adoles Psychiatry. In press.

Practice changer

Refer adolescents with moderate to severe depression for cognitive behavioral therapy (CBT) to improve their outcomes.^1-3

Strength of recommendation

B: Two well-done randomized controlled trials (RCTs).

Schoeman Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression. The TORDIA randomized controlled trial. JAMA. 2008;299:901-913.

March JS, Silva S, Petrycki S, et al. The Treatment for Adolescents with Depression Study (TADS): long-term effectiveness and safety outcomes. Arch Gen Psychiatry. 2007;64:1132-1143.

March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression. Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA. 2004;292:807-820.

ILLUSTRATIVE CASE

Jason, a depressed 17-year-old, is brought in by his mother, who’s worried about his mood and lack of motivation. He reports that his mood has “sunk” over the last 2 months. His mother interjects that she suffers from depression herself and that she’s divorced and unable to compensate for the absence of Jason’s father. She also says that her 2 older sons, both of whom Jason is close to, recently moved out of state. Further questioning reveals that Jason has lost interest in school, sports, friends, and his part-time job; he’s pessimistic about the future and feels helpless and stuck. Jason avoids going out and spends hours on the Internet.

You consider prescribing a selective serotonin reuptake inhibitor (SSRI), but you’re concerned about the potential suicide risk—a risk that’s already elevated for teens with major depressive disorder (MDD). Would a referral to a therapist be a safer choice? Is psychotherapy alone sufficient? What type of therapy is best? Only about one third of depressed teens achieve complete remission with medication alone.

Depressive disorders are common among adolescents and young adults, affecting nearly 1 in 4 by age 24.⁴ Most seek help from primary care physicians, who typically prescribe SSRIs.⁵ Yet only about one third of depressed teens achieve complete remission with medication alone.¹ For the two thirds who continue to have depressive symptoms, the consequences can be severe. Depressive illness is associated with family conflict, smoking and substance abuse, impaired functioning in school and in relationships, and increased risk of suicide—the third leading cause of death in adolescents.⁶

Drugs, psychotherapy, or both?

While CBT alone was not significantly better than placebo, it had a protective effect on suicidal events.The Guidelines for Adolescent Depression in Primary Care (GLAD-PC), published in November 2007, encourage primary care physicians to take a more active role in detecting and managing adolescent depression.⁷ GLAD-PC and the American Academy of Child and Adolescent Psychiatry recommend that teens with depressive illness receive psychotherapy, either as primary treatment or in conjunction with antidepressants.^7,8 Until recently, however, that recommendation lacked definitive evidence to support it.

STUDY SUMMARIES

2 studies explore combination approach

TADS (Treatment for Adolescents with Depression Study)^2,3 and TORDIA (Treatment of Resistant Depression in Adolescents)¹ are the only 2 randomized trials to address the role of CBT in combination with antidepressants in treating this patient population. Both show a significant benefit when CBT is added to drug therapy.

TADS: Highest improvement rates with fluoxetine and CBT

The TADS team studied 439 adolescents (ages 12 to 17 years) diagnosed with MDD. Patients were evaluated at consent, baseline, and weeks 6, 12, 18, 30, and 36. Those who were already taking antidepressants were excluded, but concurrent therapy for attention-deficit hyperactivity disorder was permitted.

Participants were randomly assigned to 1 of the following 12-week treatment options:
•Fluoxetine (10-40 mg/d)
•CBT
•Fluoxetine (10-40 mg/d) + CBT
•Placebo

CBT consisted of 15 sessions over 12 weeks, each lasting 50 to 60 minutes. In addition to individual sessions, 2 parental sessions and 1 to 3 family sessions were included. Primary outcome measures were the Clinical Global Impressions-Improvement Scale (CGI-I), which is based on a clinician’s overall assessment of the patient’s improvement; and the Children’s Depression Rating Scale-Revised (CDRS-R), which is derived from parent and adolescent interviews.

At 12 weeks, patients receiving fluoxetine and CBT demonstrated the highest rates of improvement: Seventy-one percent (95% confidence interval [CI], 62%-80%) were “much” or “very much” improved, vs 60.6% (95% CI, 51%-70%) of those on fluoxetine alone. In comparison, 43.2% (95% CI, 34%-52%) of patients receiving CBT alone were much or very much improved at the 12-week mark, and only 34.8% (95% CI, 26%-44%) of those on placebo.

At 18 weeks, the medication/CBT combination remained superior to either psychotherapy or fluoxetine alone. By week 30, all 3 intervention groups converged, and at 36 weeks there was virtually no difference in outcomes (FIGURE).

CBT alone has protective effect. While CBT alone was not significantly better than placebo overall, it demonstrated a protective effect with regard to suicidal events (thoughts, threats, or attempts) compared to fluoxetine. Conversely, fluoxetine accelerated the rate of improvement in mood during the first 30 weeks of treatment.

TORDIA: How to help patients after failed treatment

Brent and colleagues studied 334 patients between the ages of 12 and 18 years who were diagnosed with MDD but did not respond to initial SSRI therapy. After a 4-week trial, they were reevaluated and tapered off the medication, then randomly assigned to 1 of the following treatment groups for 12 weeks:
•Switched to a new SSRI
•Switched to venlafaxine (a selective serotonin-norepinephrine reuptake inhibitor)
•Switched to a new SSRI + CBT
•Switched to venlafaxine + CBT

All patients were reevaluated at week 12. Here, too, the CGI-I and CDRS-R were used for key outcome measures.

Adding CBT to a medication regimen was associated with an increased response rate; choice of antidepressant was not. The groups receiving CBT were significantly more likely to show improvement compared to those who were not undergoing CBT (54.8% [95% CI, 47%-62%] vs 40.5% [95% CI, 33%-48%], number needed to treat [NNT]=7).