Adding therapy helps adolescents with depression not responding to SSRIs

For adolescents with depression not responding to an initial treatment with a selective serotonin reuptake inhibitor (SSRI), switching medications and adding cognitive behavioural therapy resulted in an improvement in symptoms, compared to just changing medications, according to a study in the February 27 issue of JAMA: The Journal of the American Medical Association.

Adolescent depression is a common, chronic, recurrent and impairing condition. "Untreated depression results in impairment in school, interpersonal relationships, occupational adjustment, and increases the risk for suicidal behavior and completed suicide. Therefore, the proper treatment of adolescent depression has profound public health implications for youth in this critical stage of development," the researchers write.

Clinical guidelines for the treatment of adolescent depression recommend the prescribing of SSRI medications, psychotherapy, or both. While these treatments alone or in combination have been shown to be effective, at least 40 percent of adolescents with depression do not show an adequate clinical response to these interventions.

David Brent, M.D., of the University of Pittsburgh, and colleagues examined the relative efficacy of medication type, cognitive behavioural therapy (CBT), and the combination of both for the treatment of resistant adolescent depression. The randomized controlled trial, conducted from 2000-2006, included 334 patients, age 12 to 18 years, with a primary diagnosis of major depressive disorder who had not responded to a two-month initial treatment with an SSRI. For 12 weeks, participants were randomized to one of four treatments: switch to a second, different SSRI (paroxetine, citalopram, or fluoxetine); switch to a different SSRI plus CBT; switch to venlafaxine (a selective serotonin and noradrenergic reuptake inhibitor [SNRI], an antidepressant shown in some studies to be superior to an SSRI in the management of treatment-resistant adult depression); switch to venlafaxine plus CBT.

"In this study of adolescents with moderately severe and chronic depression who had not responded to an adequate course of treatment with an SSRI antidepressant, switching to a combination of CBT and another antidepressant resulted in a higher rate of clinical response [54.8 percent] than switching to another medication without CBT [40.5 percent]. There was no differential effect between switching to another SSRI [47.0 percent] or to venlafaxine [48.2 percent]," the authors write.

There were also no differential treatment effects on change in self-rated depressive symptoms, suicidal ideation, or on the rate of harm-related or other adverse events. There was a greater increase in diastolic blood pressure and pulse and more frequent occurrence of skin problems during venlafaxine than SSRI treatment.

"The clinician should convey hope to the adolescent with depression and his or her family that, despite a first unsuccessful treatment for depression, persistence with additional appropriate interventions can result in substantial clinical improvement," the researchers conclude.

(Source: JAMA: JAMA Archives: March 2008)