Two-Pronged Approach Helps Adolescents Who Don’t Respond to Initial Antidepressant Alone
By Kathleen Doheny
WebMD Medical News
Reviewed by Louise Chang, MD
WebMD Medical News
Reviewed by Louise Chang, MD
Feb. 26, 2008 -- Depressed teens who don't respond well to the first antidepressantmedication they are prescribed do improve if they are switched to a different antidepressant medication and also offered "talk" therapy, according to a new study.
The combination -- switching medications and offering talk therapy -- works better than simply changing medications, the researchers found, although switching medications alone also offers improvement.
"This validates our clinical hunch about what to do with these kids," says study researcher David Brent, MD, professor of psychiatry at the University of Pittsburgh. "Which is, if the medicine isn't working, switch it, and if they aren't getting cognitive behavioral therapy (talk therapy), you should add it."
About 40% of teens with clinical depression don't respond well when treated initially with commonly prescribed antidepressants known as SSRIs (selective serotonin reuptake inhibitors), experts say. How to help these adolescents has been an ongoing challenge. Results of the new study, published in The Journal of the American Medical Association, are expected to offer important guidance.
Depressed Teens Study: Four Options
From 2000 to 2006, researchers from the University of Pittsburgh and five other universities and clinics nationwide evaluated 334 clinically depressed teens, aged 12 to 18, who had not responded to a two-month initial treatment with an SSRI antidepressant. They assigned the teens to one of four groups for 12 weeks.
One group was switched to another SSRI antidepressant, such as Paxil, Celexa, or Prozac. Another group was switched to a different SSRI antidepressant than they took initially, plus given talk therapy. A third group was switched to the antidepressant Effexor, which is known as an SNRI (serotonin and norepinephrine reuptake inhibitor). The fourth group got Effexor plus talk therapy.
Effexor was selected, Brent says, because "at the time we designed the study there were studies in adults that found Effexor was more effective for difficult-to-treat depression." The teens studied had been clinically depressed for two years, Brent says.
Up to 12 sessions of talk therapy were offered during the study, and some sessions included family members.
The researchers evaluated improvements in depression with commonly used scales and interview questions.
Study Results
Teens switched to another medication -- either an SSRI or Effexor -- plus talk therapy improved more than those just switched to another medication. Nearly 55% of those given talk therapy and a new medication showed improvement in their depression, but improvement was seen in just 40.5% of those whose medication was switched but who did not get talk therapy.
No substantial differences were found between the two types of antidepressants. Overall, 47% of those on an SSRI improved while 48.2% of those on Effexor did.
Teens who were also on sleep medications, either prescription or over-the-counter, did not do as well as those not taking such medications, Brent says, but the reason is not clear.
The study was funded by the National Institute of Mental Health.
Message for Depressed Teens
For parents and teens, the advice is clear about what to do if the initial medication doesn't work, says Joan Rosenbaum Asarnow, PhD, professor of psychiatry at the University of California Los Angeles and a study researcher. "They should not only consider switching therapy but consider getting their child into cognitive behavioral therapy," she says. "The real finding here is that combining medication with cognitive behavioral therapy is what makes the difference in outcome."
"The most important advice is don't give up," adds Brent. "Even in the kids who only got a medication switch, 40% of them responded."
'Encouraging' Findings
Other experts not involved in the study say the findings are encouraging for tough cases. The good news is that over time the majority of adolescents can and do respond to a combination of interventions, says David Fassler, MD, a clinical professor of psychiatry at the University of Vermont, Burlington. "The study underscores the importance of altering or modifying treatment based on an ongoing assessment of clinical response."
"This study confirms some things we already know," says Nada Stotland, MD, president-elect of the American Psychiatric Association and professor of psychiatry at Rush Medical College in Chicago. "And that is that many people need to try more than one antidepressant before they find the one that works, and that as a whole, no antidepressant is better than another for a whole population, but for individual persons, one is clearly better than another." The study also confirms the value of talk therapy, she says, which may be enough for mild cases of depression.
