The treatment of adolescent depres- sion has stirred much controversy in recent years. Many have raised doubts about the efficacy of both antidepressants and psychotherapy, and whether medica- tions increase the risk of treatment— emergent suicidality is a divisive issue. Recently, the long-term results from the Treatment for Adolescents with Depression (TADS) study were published and they provide some guidance.
A total of 439 depressed adolescents were assigned to receive one of four treatments: a) cognitive-behavioral thera- py (CBT); b) Prozac (fluoxetine); c) CBT + Prozac; or d) placebo. After 12 weeks of treatment, patients getting combined Prozac and CBT improved more than those assigned to other active treatments or placebo. The study was then extended beyond 12 weeks, although all treaments were unblinded and patients originally assigned to placebo were treated “open- ly” by researchers, meaning that they active treatments yielded the same overall remission rate of 60%, meaning that both CBT alone and Prozac alone “caught up” with combined treatment. After 36 weeks, all patients were switched to community treatment and were observed for one year. At the end of this follow-up period (nearly two years from the begin- ning of the study) about three-quarters of patients in all groups showed a treatment response and two-thirds of patients showed remission (TADS Team Am J Psychiatry; online ahead of print). One concerning finding was that patients receiving Prozac were most likely to show significant suicidal ideation or behavior (15% for fluoxetine, 8% for combined, and 6% for CBT; no completed suicides occurred).
TCPR's Take: These results suggest that combining Prozac with CBT leads to the most rapid improvement in adolescent depression but that CBT or fluoxetine monotherapy eventually “catch up” in their efficacy. Also, adding CBT to treatment appears to protect against the suicidal ideation associated with Prozac treatment. Do these results extend to antidepressants other than Prozac? Maybe not, because trials of other antidepres- sants for pediatric depression have been unimpressive, with treatments showing little to no efficacy over placebo (Bridge JA et al., JAMA 2007;297:1683-1696). And Prozac remains the only medication with an FDA indication for depression in children.
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