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Researchers find depressed teens respond well to combination therapy

February 27, 2008

More than half of teenagers with the most debilitating forms of depression that do not respond to treatment with selective serotonin reuptake inhibitors (SSRIs) show improvement after switching to a different medication combined with cognitive behavioral therapy, researchers at UT Southwestern Medical Center and their colleagues in a multicenter study have found.

Dr. Graham Emslie, professor of psychiatry and pediatrics at UT Southwestern and chief of child and adolescent psychiatry at Children's Medical Center Dallas, was a principal investigator in the study appearing in the Feb. 27 issue of the Journal of the American Medical Association.

"If an adolescent hasn't responded to an initial treatment, go ahead and switch treatments," said Dr. Emslie. "Our results should encourage clinicians to not let an adolescent stay on the same medication and still suffer." The 334 study participants suffered from depression on average for about two years. The teenagers involved exhibited moderate to severe major depressive disorder, many with suicidal ideation. Historically, these types of patients have the worst treatment outcomes.

The researchers found that nearly 55 percent of teenagers who failed to respond to a class of antidepressant medications known as SSRIs, responded when they switched to a different antidepressant and participated in cognitive behavioral therapy, which examines thinking patterns to modify behavior.

The study also found that about 41 percent of participants responded after switching to either a different SSRI or to venlafaxine, a different kind of depression medication.

SSRIs are the most common treatment for teenage depression, although previous studies have shown that about 40 percent of teenagers on the drugs don't respond to the first treatment.

"This is a group that has been suffering from a serious medical condition for a long time," said Dr. Emslie, the first psychiatrist to demonstrate antidepressants are effective in depressed children and adolescents. "It's important that the adolescent not give up."

The study participants, who ranged in age from 12 to 18 and came from six sites across the country, were evaluated between 2000 and 2006. Participants who had failed to improve with an SSRI were randomly assigned to a 12-week regimen of one of four treatments that either called for switching to:

* a different SSRI;
* a different SSRI plus cognitive behavioral therapy;
* venlafaxine only, or;
* venlafaxine plus cognitive behavioral therapy.

Improvement was measured using the Clinical Global Impressions Scale and Children's Depression Rating Scale-Revised.

The results showed that medication and therapy do not have to be independent of each other.

"If you haven't had a good response with antidepressants, definitely add cognitive behavioral therapy," Dr. Emslie said. "Having them work together is probably the most beneficial."

The study results are similar to research findings from the UT Southwestern-led STAR*D, or Sequenced Treatment Alternatives to Relieve Depression, study on adult depression. The largest depression study of its kind, STAR*D has demonstrated that one in three to four adults who did not achieve full remission of symptoms from one antidepressant medication became symptom-free after changing or adding a second medication.

"One major question of psychiatrists is whether depression is different in adolescence," Dr. Emslie said. "This research suggests this disease is present in adolescence and very similar to what happens in adulthood. It's important to identify and treat depression early.

Dr. Emslie and his colleagues are continuing their studies on teenage depression and will use the data to refine treatment guidelines.

Other researchers at UT Southwestern who participated in the study include Dr. Beth Kennard, associate professor of psychiatry, and Dr. Carroll Hughes, professor of psychiatry. Researchers at the University of Pittsburgh; Kaiser Permanente Center for Health Research in Portland, Ore.; UT Medical Branch in Galveston; the University of California, Los Angeles; and Brown University also participated in the research.

The study was funded by the National Institute of Mental Health.

The University of Texas Southwestern Medical Center at Dallas