Combo Therapy Best for Teen Depression

Prozac plus cognitive behavioral therapy better than either alone, finds study

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HealthDay Reporter

TUESDAY, Aug. 17, 2004 (HealthDayNews) -- When it comes to treating teenage depression, two treatments appear to be better than one.

Almost three out of four depressed teens reported feeling better when they were treated with a combination of an antidepressant and cognitive behavioral therapy, reports a study in the Aug. 18 issue of the Journal of the American Medical Association.

Each treatment option alone helped significantly fewer teens. Only 60 percent reported improvement only on the medication, a selective serotonin reuptake inhibitor (SSRI) known as fluoxetine (Prozac), while just 43 percent reported feeling better after therapy alone, the researchers found.

"Combination therapy was clearly the big winner," said study author Dr. John March, chief of child and adolescent psychiatry at Duke University Medical Center. "Kids responded better, had lower suicide rates and it seemed to ameliorate some of the risk for self-harm."

The treatment of adolescent depression has been a hot topic lately because some studies have found an association between antidepressant use in depressed teenagers and suicidal thoughts. In fact, in March 2004, the U.S. Food and Drug Administration asked the manufacturers of 10 antidepressants to add more detailed and easily visible warnings to their labels about the potential for deepening depression and suicidal thoughts, especially in teens.

But some experts contend it isn't the medication that's increasing suicidal thoughts, but simply the natural course of depression. One thing all experts seem to agree on, however, is that more study of the potential side effects of these medications is needed, particularly in children.

"We really need to know specifically how treatments are going to affect children, because children are not little adults," said Dr. Jason Wuttke, a pediatric psychiatrist at Ochsner Clinic Foundation Hospital in New Orleans.

While the current study doesn't definitively settle the debate on antidepressant use in teens, it does lend credence to the use of at least one such medication for the treatment of adolescent depression.

March and his colleagues recruited teenagers from 13 different centers across the United States for the study, called Treatment for Adolescents with Depression Study (TADS). The researchers included 439 children between the ages of 12 and 17 who had been diagnosed as having a major depressive disorder.

The teens were randomized into one of four groups: fluoxetine alone (10 to 40 milligrams daily), cognitive behavioral therapy alone (15 one-hour sessions), a combination of fluoxetine and therapy, or a placebo.

March described the cognitive behavior therapy portion as a three-legged stool. One leg targeted negative thinking and helped teens identify these thoughts and change them. Another leg was designed to change a depressed teen's behavior. For example, rather than withdrawing socially and spending all their time locked in their bedrooms, teens were encouraged to do things that made them feel more successful. The final leg of the stool was education, particularly of family members to teach them better ways to interact.

After 12 weeks, the combination therapy proved most successful, with a 71 percent response rate. Fluoxetine alone had a 60.6 percent response rate, and CBT alone a 43.2 percent response rate. Those on placebo had a 34.8 percent response rate.

In all four groups, thoughts of suicide were down by the end of the study. Again, those on combination therapy fared best, with the greatest reduction in suicidal thoughts.

But harm-related behaviors were slightly more likely to occur in those teens taking the antidepressant alone. Harm-related behaviors include "cutting," increased suicidal thoughts, suicide attempt, harm to others or destruction of property.

However, the researchers found therapy lowered the risk of harm-related behaviors, and did so significantly enough to offset the increase in these behaviors in teens taking fluoxetine alone.

There were seven attempted suicides during the course of the study, although none were completed. Four involved teens on the combination therapy, two involved those on the antidepressant alone and one involved a teenager receiving cognitive behavioral therapy alone.

"Although the TAD results certainly do not provide a definitive answer to the recent concerns about SSRI treatment and suicidality among adolescents, it is of interest and clinical importance that suicidal ideation decreased in all four treatment groups, with the suggestion of a particularly beneficial effect for [cognitive behavioral therapy]," said Dr. Richard Glass, deputy editor of the journal in an accompanying editorial.

Wuttke said, "The combination of treatment with fluoxetine along with cognitive behavioral therapy is a safe and effective treatment, and now it's empirically validated."

In his editorial, Glass agreed: "Perhaps most important is the finding that treatment of carefully evaluated adolescents with moderate to severe major depression can be effective within 12 weeks."

March added, "There's no question that fluoxetine is an effective treatment for depression, but like any drug, it has a side effect profile. This drug is neither extreme nor innocuous. Like any medication, it requires careful monitoring."

"Although this is not something that can be handled in a 15-minute office visit, medical management with fluoxetine is an important part of treatment. For most kids, the ideal treatment for depression is the combination of fluoxetine and cognitive behavioral therapy," March said.

More information

To learn more about teen depression, visit the National Mental Health Association.

SOURCES: John March, M.D., professor, and chief, child and adolescent psychiatry, Duke University Medical Center, Durham, N.C.; Jason Wuttke, M.D., pediatric psychiatrist, Ochsner Clinic Foundation Hospital, New Orleans; Aug. 18, 2004, Journal of the American Medical Association

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