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Rohden AI, Benchaya MC, Camargo RS, Moreira TDC, Barros HM, Ferigolo M. Dropout Prevalence and Associated Factors in Randomized Clinical Trials of Adolescents Treated for Depression: Systematic Review and Meta-analysis. Clin Ther 2017; 39:971-992.e4. [DOI: 10.1016/j.clinthera.2017.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/02/2017] [Accepted: 03/13/2017] [Indexed: 12/29/2022]
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Magavi LR, Reti IM, Vasa RA. A review of repetitive transcranial magnetic stimulation for adolescents with treatment-resistant depression. Int Rev Psychiatry 2017; 29:79-88. [PMID: 28306351 DOI: 10.1080/09540261.2017.1300574] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This review examines the efficacy and safety of repetitive transcranial magnetic stimulation (rTMS) as a treatment for treatment-resistant depression in adolescents. A systematic review of six databases was conducted. Ten multi-subject trials, all uncontrolled, and five case reports met inclusion criteria. Twelve studies focused on treatment efficacy, whereas three studies focused exclusively on adverse events. All efficacy studies focused on adolescents only; 10 of these studies indicated that rTMS may demonstrate some benefit. Improvement within 2-8 weeks was reported in most studies, with a few studies indicating potential long-term benefits. A variety of adverse events occurred including scalp pain, which was the most common, as well as seizures. Controlled studies of rTMS are warranted to further examine whether this treatment is a potential option for adolescents with treatment-resistant depression.
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Affiliation(s)
| | | | - Roma A Vasa
- a Johns Hopkins Hospital , Baltimore , MD , USA
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53
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Isa A, Bernstein I, Trivedi M, Mayes T, Kennard B, Emslie G. Understanding the Impact of Treatment on the Dimensions of Childhood Depression. J Child Adolesc Psychopharmacol 2017; 27:160-166. [PMID: 26862813 PMCID: PMC9836682 DOI: 10.1089/cap.2015.0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Childhood depression is often chronic and recurrent, with only modest improvements after optimal treatments. Novel approaches are needed for accurate diagnosis, timely selection of the best treatment for childhood depression, and improvement of remission rates. An important part of diagnosis is to determine how many consistent dimensions underlie childhood depression and what impact treatment may have on these dimensions. OBJECTIVE The goal of the current study is evaluate the consistency of the number of depressive symptom dimensions and examine the effect of depression treatment on the change in dimensions by seeing if this dimensional structure is the same for groups that were given a placebo and groups that were given an active drug, fluoxetine. METHODS We examined a combined sample of three clinical trials data sets with a total of 269 placebo patients and 261 fluoxetine patients at baseline, and 253 placebo patients and 249 fluoxetine patients at exit. Principal components analysis with associated parallel analysis followed by a ProMax oblique rotation was conducted on each week's scores. The similarity of the rotated structures between treatments and between weeks was then assessed using Wrigley and Neuhaus' (1955) degree of factorial similarity measure, which is a correlation-like statistic that takes two solutions based upon the same measures and assesses how similar they are. RESULTS Preliminary analysis indicated that mean scores of both treatment groups declined from baseline to exit, but the decline was greater for the fluoxetine group. There were four dimensions at baseline and two dimensions at exit in each treatment group. Hence the numbers of dimensions were the same in the two groups, whereas the content of the components was the same at baseline for the two groups, but was different at exit. Basically, the factorial similarities of the rotated factors were very high at baseline between the two groups for both factors (Ψ = 0.97 for factor I and 0.94 for factor II) before they were treated differently. However, at exit, the respective similarities dropped to 0.58 and -0.04 for factors I and II. Therefore, time had a large effect in changing both groups' factor structure, but it was especially large when there was an active treatment. CONCLUSIONS In comparing the baseline and exit dimensions in a forced two factor solution of two treatment groups, it was revealed that treatment did have an impact on the change in dimensions. These results further the generality of the simplification of the factor structure of the Childhood Depression Rating Scale- Revised (CDRS-R) over time. In addition, these results show the effect of time and therapy on the factor structures. The fluoxetine group followed the trend of the content of the dimensions revealed in a previous study, whereas the placebo group had a less distinct change over time.
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Affiliation(s)
- Ameena Isa
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ira Bernstein
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Madhukar Trivedi
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Taryn Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas.,Division of Child and Adolescent Psychiatry, Children's Medical Center, Dallas, Texas
| | - Betsy Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas.,Division of Child and Adolescent Psychiatry, Children's Medical Center, Dallas, Texas
| | - Graham Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas.,Division of Child and Adolescent Psychiatry, Children's Medical Center, Dallas, Texas
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Rith-Najarian LR, Park AL, Wang T, Etchison AI, Chavira DA, Chorpita BF. Applying new evidence standards to youth cognitive behavioral therapies - A review. Behav Res Ther 2017; 90:147-158. [PMID: 28061375 DOI: 10.1016/j.brat.2016.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 11/11/2016] [Accepted: 12/16/2016] [Indexed: 12/19/2022]
Abstract
This review included 136 published randomized controlled trials (RCTs) of youth cognitive behavioral therapy (CBT) treatments. We aimed to test the premise that evidence-based youth treatments can be better differentiated from each other by applying more nuanced standards of evidence. Accordingly, we applied three standards to this article sample to determine how many treatments produced significant results: (a) on multiple target symptom measures, (b) at follow-up, and/or (c) against an active comparison group. We identified how many trials met standards individually and in combination. Although 87 of the 136 articles produced at least one significant treatment result at post-assessment, the subsets of "passing" articles were smaller and varied for any one of our three standards, with only 11 articles (8%) meeting all three standards simultaneously. Implications are discussed regarding the definition of "evidence-based," the need for multi-parameter filtering in treatment selection and clinical decision making, and future directions for research. We ultimately argue the value in assessing youth treatments for different types of evidence, which is better achieved through dynamic sets of standards, rather than a single approach to assessing general strength of evidence.
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Affiliation(s)
- Leslie R Rith-Najarian
- Department of Psychology, University of California, Los Angeles 1285 Franz Hall, Los Angeles, CA, 90095, USA.
| | - Alayna L Park
- Department of Psychology, University of California, Los Angeles 1285 Franz Hall, Los Angeles, CA, 90095, USA
| | - Tina Wang
- Department of Psychology, University of California, Los Angeles 1285 Franz Hall, Los Angeles, CA, 90095, USA
| | - Ana I Etchison
- Department of Psychology, University of California, Los Angeles 1285 Franz Hall, Los Angeles, CA, 90095, USA
| | - Denise A Chavira
- Department of Psychology, University of California, Los Angeles 1285 Franz Hall, Los Angeles, CA, 90095, USA
| | - Bruce F Chorpita
- Department of Psychology, University of California, Los Angeles 1285 Franz Hall, Los Angeles, CA, 90095, USA
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Weersing VR, Jeffreys M, Do MCT, Schwartz KTG, Bolano C. Evidence Base Update of Psychosocial Treatments for Child and Adolescent Depression. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2016; 46:11-43. [PMID: 27870579 DOI: 10.1080/15374416.2016.1220310] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Depression in youth is prevalent and disabling and tends to presage a chronic and recurrent course of illness and impairment in adulthood. Clinical trial research in youth depression has a 30-year history, and evidence-based treatment reviews appeared in 1998 and 2008. The current review of 42 randomized controlled trials (RCTs) updates these reviews to include RCTs published between 2008 and 2014 (N = 14) and reevaluates previously reviewed literature. Given the growing maturity of the field, this review utilized a stringent set of methodological criteria for trial inclusion, most notable for excluding trials based in subclinical samples of youth that had been included in previous reviews (N = 12) and including well-designed RCTs with null and negative findings (N = 8). Findings from the current review suggest that evidence for child treatments is notably weaker than for adolescent interventions, with no child treatments achieving well-established status and the evidentiary basis of treatments downgraded from previous reports. Cognitive behavioral therapy (CBT) for clinically depressed children appears to be possibly efficacious, with mixed findings across trials. For depressed adolescents, both CBT and interpersonal psychotherapy are well-established interventions, with evidence of efficacy in multiple trials by independent investigative teams. This positive conclusion is tempered by the small size of the interpersonal psychotherapy literature (N = 6) and concern that CBT effects may be attenuated in clinically complicated samples and when compared against active control conditions. Data on predictors, moderators, and mediators are examined and priorities for future research discussed.
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Affiliation(s)
- V Robin Weersing
- a SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology.,b Department of Psychology , San Diego State University
| | - Megan Jeffreys
- a SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology
| | - Minh-Chau T Do
- a SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology
| | | | - Carl Bolano
- b Department of Psychology , San Diego State University
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Fristad MA, Vesco AT, Young AS, Healy KZ, Nader ES, Gardner W, Seidenfeld AM, Wolfson HL, Arnold LE. Pilot Randomized Controlled Trial of Omega-3 and Individual-Family Psychoeducational Psychotherapy for Children and Adolescents With Depression. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2016; 48:S105-S118. [PMID: 27819485 PMCID: PMC6066443 DOI: 10.1080/15374416.2016.1233500] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The goal of this study is to evaluate feasibility and estimate effect sizes of omega-3 fatty acids (Ω3), individual-family psychoeducational psychotherapy (PEP), their combination, and moderating effects of maternal depression and psychosocial stressors in youth with depression. In a pilot 2 × 2 randomized controlled trial, 72 youth (ages 7-14; 57% Caucasian, 57% male) with major depression, dysthymia, or depression not otherwise specified were randomized to 12 weeks of Ω3, PEP+placebo, Ω3+PEP, or placebo. Ω3 versus placebo was double-masked. Evaluators masked to condition assessed depressive severity at baseline (randomization) and at 2, 4, 6, 9, and 12 weeks using the Children's Depression Rating Scale-Revised. Side effects were either absent or mild. PEP was administered with 74% fidelity. Remission was 77%, Ω3+PEP; 61%, PEP+placebo; 44%, Ω3; 56%, placebo. Intent-to-treat analyses found small to medium effects of combined treatment (d = .29) and Ω3 monotherapy (d = .42), but negligible effect for PEP+placebo (d < .10), all compared to placebo alone. Relative to placebo, youth with fewer social stressors responded better to Ω3 (p = .04), PEP (p = .028), and their combination (p = .035), and those with maternal depression responded better to PEP (p = .020) than did those without maternal depression. Remission rates were favorable compared to other studies of psychotherapy and comparable to an existing randomized controlled trial of Ω3; results warrant further evaluation in a larger sample. Ω3 was well tolerated. Active treatments show significantly more placebo-controlled depression improvement in the context of maternal depression and fewer stressors, suggesting that they may benefit depression with a more endogenous than environmental origin.
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Affiliation(s)
- Mary A Fristad
- a Department of Psychiatry and Behavioral Health , The Ohio State University Wexner Medical Center
| | - Anthony T Vesco
- a Department of Psychiatry and Behavioral Health , The Ohio State University Wexner Medical Center
| | - Andrea S Young
- a Department of Psychiatry and Behavioral Health , The Ohio State University Wexner Medical Center
| | - K Zachary Healy
- a Department of Psychiatry and Behavioral Health , The Ohio State University Wexner Medical Center
| | - Elias S Nader
- a Department of Psychiatry and Behavioral Health , The Ohio State University Wexner Medical Center
| | - William Gardner
- a Department of Psychiatry and Behavioral Health , The Ohio State University Wexner Medical Center
| | - Adina M Seidenfeld
- a Department of Psychiatry and Behavioral Health , The Ohio State University Wexner Medical Center
| | - Hannah L Wolfson
- a Department of Psychiatry and Behavioral Health , The Ohio State University Wexner Medical Center
| | - L Eugene Arnold
- a Department of Psychiatry and Behavioral Health , The Ohio State University Wexner Medical Center
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Loades ME, Sheils EA, Crawley E. Treatment for paediatric chronic fatigue syndrome or myalgic encephalomyelitis (CFS/ME) and comorbid depression: a systematic review. BMJ Open 2016; 6:e012271. [PMID: 27729349 PMCID: PMC5073581 DOI: 10.1136/bmjopen-2016-012271] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/27/2016] [Accepted: 07/28/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES At least 30% of young people with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) also have symptoms of depression. This systematic review aimed to establish which treatment approaches for depression are effective and whether comorbid depression mediates outcome. SETTING A systematic review was undertaken. The search terms were entered into MEDLINE, EMBASE, PsycInfo and the Cochrane library. PARTICIPANTS Inclusion and exclusion criteria were applied to identify relevant papers. Inclusion criteria were children age <18, with CFS/ME, defined using CDC, NICE or Oxford criteria, and having completed a valid assessment for depression. RESULTS 9 studies were identified which met the inclusion criteria, but none specifically tested treatments for paediatric CFS/ME with depression and none stratified outcome for those who were depressed compared with those who were not depressed. There is no consistent treatment approach for children with CFS/ME and comorbid depression, although cognitive-behavioural therapy for CFS/ME and a multicomponent inpatient programme for CFS/ME have shown some promise in reducing depressive symptoms. An antiviral medication in a small scale, retrospective, uncontrolled study suggested possible benefit. CONCLUSIONS It is not possible to determine what treatment approaches are effective for depression in paediatric CFS/ME, nor to determine the impact of depression on the outcome of CFS/ME treatment. Young people with significant depression tend to have been excluded from previous treatment studies.
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Affiliation(s)
| | | | - Esther Crawley
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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58
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Cullen KR, Klimes-Dougan B, Vu DP, Westlund Schreiner M, Mueller BA, Eberly LE, Camchong J, Westervelt A, Lim KO. Neural Correlates of Antidepressant Treatment Response in Adolescents with Major Depressive Disorder. J Child Adolesc Psychopharmacol 2016; 26:705-712. [PMID: 27159204 PMCID: PMC5069704 DOI: 10.1089/cap.2015.0232] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The neural changes underlying response to antidepressant treatment in adolescents are unknown. Identification of neural change correlates of treatment response could (1) aid in understanding mechanisms of depression and its treatment and (2) serve as target biomarkers for future research. METHOD Using functional magnetic resonance imaging, we examined changes in brain activation and functional connectivity in 13 unmedicated adolescents with major depressive disorder (MDD) before and after receiving treatment with a selective serotonin reuptake inhibitor medication for 8 weeks. Specifically, we examined brain activation during a negative emotion task and resting-state functional connectivity (RSFC), focusing on the amygdala to capture networks relevant to negative emotion. We conducted whole-brain analyses to identify how symptom improvement was related to change in brain activation during a negative emotion task or amygdala RSFC. RESULTS After treatment, clinical improvement was associated with decreased task activation in rostral and subgenual anterior cingulate cortex and increased activation in bilateral insula, bilateral middle frontal cortices, right parahippocampus, and left cerebellum. Analysis of change in amygdala RSFC showed that treatment response was associated with increased amygdala RSFC with right frontal cortex, but decreased amygdala RSFC with right precuneus and right posterior cingulate cortex. CONCLUSION The findings represent a foothold for advancing understanding of pathophysiology of MDD in adolescents by revealing the critical neural circuitry changes that underlie a positive response to a standard treatment. Although preliminary, the present study provides a research platform for future work needed to confirm these biomarkers at a larger scale before using them in future target engagement studies of novel treatments.
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Affiliation(s)
- Kathryn R. Cullen
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota
| | | | | | | | - Bryon A. Mueller
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota
| | - Lynn E. Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Jazmin Camchong
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota
| | - Ana Westervelt
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota
| | - Kelvin O. Lim
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota
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59
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Sasaki T, Hashimoto K, Oda Y, Ishima T, Yakita M, Kurata T, Kunou M, Takahashi J, Kamata Y, Kimura A, Niitsu T, Komatsu H, Hasegawa T, Shiina A, Hashimoto T, Kanahara N, Shimizu E, Iyo M. Increased Serum Levels of Oxytocin in 'Treatment Resistant Depression in Adolescents (TRDIA)' Group. PLoS One 2016; 11:e0160767. [PMID: 27536785 PMCID: PMC4990411 DOI: 10.1371/journal.pone.0160767] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 07/25/2016] [Indexed: 11/18/2022] Open
Abstract
Objective ‘Treatment-resistant depression’ is depression that does not respond to an adequate regimen of evidence-based treatment. Treatment-resistant depression frequently becomes chronic. Children with treatment-resistant depression might also develop bipolar disorder (BD). The objective of this study was to determine whether serum levels of oxytocin (OXT) in treatment-resistant depression in adolescents (TRDIA) differ from non-treatment-resistant depression in adolescents (non-TRDIA) or controls. We also investigated the relationships between serum OXT levels and the clinical symptoms, severity, and familial histories of adolescent depressive patients. Methods We measured serum OXT levels: TRDIA (n = 10), non-TRDIA (n = 27), and age- and sex- matched, neurotypical controls (n = 25). Patients were evaluated using the Children’s Depression Rating Scale-Revised (CDRS-R) and the Depression Self-Rating Scale for Children-Japanese Version (DSRS-C-J). The patients were also assessed retrospectively using the following variables: familial history of major depressive disorder and BD (1st degree or 2nd degree), history of disruptive mood dysregulation disorder, recurrent depressive disorder (RDD), history of antidepressant activation. Results Serum levels of OXT among the TRDIA and non-TRDIA patients and controls differed significantly. Interestingly, the rates of a family history of BD (1st or 2nd degree), RDD and a history of antidepressant activation in our TRDIA group were significantly higher than those of the non-TRDIA group. Conclusions Serum levels of OXT may play a role in the pathophysiology of TRDIA.
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Affiliation(s)
- Tsuyoshi Sasaki
- Department of Child Psychiatry, Chiba University Hospital, Chiba, Japan
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
- * E-mail:
| | - Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, Japan
| | - Yasunori Oda
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tamaki Ishima
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, Japan
| | - Madoka Yakita
- Department of Child Psychiatry, Chiba University Hospital, Chiba, Japan
| | - Tsutomu Kurata
- Department of Child Psychiatry, Chiba University Hospital, Chiba, Japan
| | - Masaru Kunou
- Department of Child Psychiatry, Chiba University Hospital, Chiba, Japan
- Departments of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Jumpei Takahashi
- Department of Child Psychiatry, Chiba University Hospital, Chiba, Japan
| | - Yu Kamata
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
| | - Atsushi Kimura
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tomihisa Niitsu
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hideki Komatsu
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tadashi Hasegawa
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
| | - Akihiro Shiina
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tasuku Hashimoto
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
| | - Nobuhisa Kanahara
- Division of Medical Treatment and Rehabilitation, Chiba University Center for Forensic Mental Health, Chiba, Japan
| | - Eiji Shimizu
- Departments of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaomi Iyo
- Department of Child Psychiatry, Chiba University Hospital, Chiba, Japan
- Departments of Psychiatry Chiba University Graduate School of Medicine, Chiba, Japan
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, Japan
- Division of Medical Treatment and Rehabilitation, Chiba University Center for Forensic Mental Health, Chiba, Japan
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Devenish B, Berk L, Lewis AJ. The treatment of suicidality in adolescents by psychosocial interventions for depression: A systematic literature review. Aust N Z J Psychiatry 2016; 50:726-40. [PMID: 26896044 DOI: 10.1177/0004867415627374] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Given depression is a significant risk factor for suicidal behaviour, it is possible that interventions for depression may also reduce the risk of suicide in adolescents. The purpose of this literature review is to determine whether psychological interventions aimed to prevent and/or treat depression in adolescents can also reduce suicidality. METHODS We conducted a systematic review of psychological interventions aimed to prevent and/or treat depression in adolescents in which outcomes for suicidality were reported, using five databases: PsycINFO, Embase, Medline, CINAHL and Scopus. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS A total of 35 articles pertaining to 12 treatment trials, two selective prevention trials and two universal prevention trials met inclusion criteria. No studies were identified that used a no-treatment control. In both intervention and active control groups, suicidality decreased over time; however, most structured psychological depression treatment interventions did not outperform pharmaceutical or treatment as usual control groups. Depression prevention studies demonstrated small but statistically significant reductions in suicidality. LIMITATIONS Analysis of study quality suggested that at least 10 of the 16 studies have a high risk of bias. Conclusive comparisons across studies are problematic due to differences in measures, interventions, population differences and control groups used. CONCLUSIONS It is unclear whether psychological treatments are more effective than no treatment since no study has used a no-treatment control group. There is evidence to suggest that Cognitive Behavioural Therapy interventions produce pre-post reductions in suicidality with moderate effect sizes and are at least as efficacious as pharmacotherapy in reducing suicidality; however, it is unclear whether these effects are sustained. There are several trials showing promising evidence for family-based and interpersonal therapies, with large pre-post effect sizes, and further evaluation with improved methodology is required. Depression prevention interventions show promising short-term effects.
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Affiliation(s)
- Bethany Devenish
- Faculty of Health, School of Psychology, Deakin University, Burwood, Australia
| | - Lesley Berk
- Faculty of Health, School of Psychology, Deakin University, Burwood, Australia Department of Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, Deakin University, Burwood, Australia
| | - Andrew J Lewis
- Faculty of Health, School of Psychology, Deakin University, Burwood, Australia School of Psychology and Exercise Science, Murdoch University, Murdoch WA, Australia
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Abstract
Depression is the most common mental health disorder in children and adolescents, and primary care is often the first point of contact for children and adolescents with depression. Depression impacts all areas of life, impairing academics and interactions with family and friends. The purpose of this article is to help NPs identify and treat children and adolescents presenting with depression in the primary care setting.
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Affiliation(s)
- Judy Haefner
- Judy Haefner is an assistant professor at the University of Michigan, Flint, Mich
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62
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Effective Treatment of Depressive Disorders in Medical Clinics for Adolescents and Young Adults Living With HIV: A Controlled Trial. J Acquir Immune Defic Syndr 2016; 71:38-46. [PMID: 26761270 DOI: 10.1097/qai.0000000000000803] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Preliminary test of a manualized, measurement-guided treatment for depression for adolescents and young adults in care at 4 sites of the Adolescent Trials Network for HIV/AIDS Interventions. DESIGN The US sites were randomly assigned to either a 24-week, combination cognitive behavioral therapy and medication management algorithm (COMB) tailored for youth living with HIV (YLWH) or to treatment as usual (TAU). METHODS Youth at TAU sites had access to therapists and medication management as needed. COMB-site clinicians were trained in the manualized intervention and participated in supervision calls to monitor intervention fidelity. RESULTS Over the course of the study with 44 participants, those in COMB, compared with those in TAU, reported fewer depressive symptoms, P < 0.01 (as measured by the Quick Inventory for Depression symptoms) and were more likely to be in remission, P < 0.001 (65% vs. 10% at week 24, end of treatment, and 71% vs. 7% at week 48, final follow-up). A greater proportion of COMB participants received psychotherapy (95% vs. 45%, P < 0.001) and attended more sessions (12.6 vs. 5, P < 0.001) than those in TAU. Viral load decreased in both groups and was associated (P < 0.05) with reduction in depressive symptoms. CONCLUSIONS A 24-week manualized, measurement-guided psychotherapy and medication management algorithm tailored for YLWH was more effective in achieving and sustaining remission from depression than TAU at HIV care clinic sites. Given observed treatment efficacy, this structured combination treatment could be disseminated to medical clinics to successfully treat YLWH, who are at particular risk for depression.
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63
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Nilsen TS, Handegård BH, Eisemann M, Kvernmo S. Predictors of rate of change for children and youth with emotional disorders: a naturalistic observational study. Child Adolesc Psychiatry Ment Health 2016; 10:11. [PMID: 27152119 PMCID: PMC4857241 DOI: 10.1186/s13034-016-0098-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 04/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To examine demographic and clinical characteristics as potential predictors of change for children and youth with emotional disorders treated at two child and adolescent mental health outpatient services (CAMHS) in Norway. METHODS The study was of naturalistic observational type with "treatment as usual" (TAU). The sample consisted of 84 children and youth with emotional disorders. The Health of the Nation Outcome Scale (HONOSCA), and the Children's Global Assessment Scale (CGAS) were administered at intake (T0), during the assessment (T1) and approximately six months after assessment (T2). Change was analysed by means of the linear mixed models procedure. RESULTS For the HONOSCA total score, youths with a diagnosis of depression had statistically higher symptom severity levels at baseline and significantly lower change rates as compared to youths with an anxiety disorder. CONCLUSIONS The current study adds to the limited knowledge of predictors of rate of change for children and adolescents with emotional disorders treated within CAMHS. Our results point to a special need to improve clinical care for depressed children and adolescents. Important limitations comprising the external validity of the study concern missing data, a small study sample, and lack of information regarding the content and extent of the service provided.
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Affiliation(s)
- Toril Sørheim Nilsen
- Research Group For Clinical Psychology, Department of Psychology, Faculty of Health Sciences, UiT The Arctic University of Norway, 9037 Tromsø, Norway ,Department of Child and Adolescent Psychiatry, Divisions of Child and Adolescent Health, University Hospital of North-Norway, P.O. Box 19, 9038 Tromsø, Norway
| | - Bjørn Helge Handegård
- Regional Centre for Child and Youth Mental Health and Child Welfare, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Martin Eisemann
- Research Group For Mental Ehealth, Department of psychology, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Siv Kvernmo
- Department of Child and Adolescent Psychiatry, Divisions of Child and Adolescent Health, University Hospital of North-Norway, P.O. Box 19, 9038 Tromsø, Norway ,Research Group of Pediatrics, Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, 9037 Tromsø, Norway
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Abstract
BACKGROUND A large and extensive body of research has examined comorbid anxiety and depression in adults. Children and adolescents also frequently present with comorbid anxiety and depression; however, research and treatment require unique environmental and neurodevelopmental considerations in children. As a result, our understanding of comorbid anxiety and depression in children and adolescents is limited. OBJECTIVE The goal of this systematic review was to examine the current literature focused on comorbid anxiety and depression in children and adolescents. The review included theoretical conceptualizations as well as diagnostic, neurobiological, prevention, and treatment considerations. In addition, a proposed algorithm for the treatment of comorbid anxiety and depression in children/adolescents is provided. METHODS This systematic literature review included 3 discrete searches in Ovid SP Medline, PsycInfo, and PubMed. RESULTS The review included and synthesized 115 articles published between 1987 and 2015. The available evidence suggests that anxiety and depression are common in clinical populations of children and adolescents, and that comorbidity is likely underestimated in children and adolescents. Children and adolescents with comorbid anxiety and depression have unique presentations, greater symptom severity, and treatment resistance compared with those who have either disease in isolation. A dimensional approach may be necessary for the future development of diagnostic strategies and treatments for this population. Nascent neuroimaging work suggests that anxiety and depression each represents a distinct neurobiological phenotype. CONCLUSIONS The literature that is currently available suggests that comorbid anxiety and depression is a common presentation in children and adolescents. This diagnostic picture underscores the importance of comprehensive dimensional assessments and multimodal evidence-based approaches given the high disease severity. Future research on the neurobiology and the treatment of these common clinical conditions is warranted.
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Garber J, Frankel SA, Herrington CG. Developmental Demands of Cognitive Behavioral Therapy for Depression in Children and Adolescents: Cognitive, Social, and Emotional Processes. Annu Rev Clin Psychol 2016; 12:181-216. [PMID: 27019397 PMCID: PMC5441981 DOI: 10.1146/annurev-clinpsy-032814-112836] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Although some treatments for depression in children and adolescents have been found to be efficacious, the effects sizes have tended to be modest. Thus, there is considerable room to improve upon existing depression treatments. Some children may respond poorly because they do not yet have the cognitive, social, or emotional maturity needed to understand and apply the skills being taught in therapy. Therefore, treatments for depression may need to be tailored to match children's ability to both comprehend and implement the therapeutic techniques. This review outlines the steps needed for such developmental tailoring: (a) Specify the skills being taught in depression treatments; (b) identify what cognitive, social, and emotional developmental abilities are needed to attain these skills; (c) describe the normative developmental course of these skills and how to determine a child's developmental level; and (d) use this information to design an individualized treatment plan. Possible approaches to intervening include: alter the therapy to meet the child's level of development, train the child on the skills needed to engage in the therapy, or apply a dynamic assessment approach that integrates evaluation into treatment and measures children's current abilities as well as their potential.
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Affiliation(s)
- Judy Garber
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee 37203-5721; , ,
| | - Sarah A Frankel
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee 37203-5721; , ,
| | - Catherine G Herrington
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee 37203-5721; , ,
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66
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Brown R, James A. Practical pharmacotherapy in child psychiatry: an update. BJPSYCH ADVANCES 2015. [DOI: 10.1192/apt.bp.114.013193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryPsychopharmacology is an increasingly important aspect of child and adolescent psychiatry. The evidence base for the psychopharmacological treatment of depression, anxiety, schizophrenia, bipolar disorder, obsessive—compulsive disorder (OCD) and attention-deficit hyperactivity disorder (ADHD) is increasing. This article presents a synthesis of the information from randomised controlled trials, meta-analyses and the UK NICE guidelines as an aid to practical psychopharmacology.
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Pettit JW, Silverman WK, Rey Y, Marin C, Jaccard J. Moving to Second-Stage Treatments Faster: Identifying Midtreatment Tailoring Variables for Youth with Anxiety Disorders. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2015; 45:457-68. [PMID: 25984794 DOI: 10.1080/15374416.2015.1038824] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The current study presents an approach for empirically identifying tailoring variables at midtreatment of cognitive behavioral therapy (CBT) protocols for youth with anxiety disorders that can be used to guide moves to second-stage treatments. Using 2 independent data sets (Study 1 N = 240, M age = 9.86 years; Study 2 N = 341; M age = 9.53 years), we examined treatment response patterns after 8 sessions of CBT (i.e., CBT midtreatment). We identified and replicated 3 classes of response patterns at CBT midtreatment: Early Responders, Partial Responders, and Nonresponders. Class membership at CBT midtreatment was predictive of outcome at CBT posttreatment. Receiver operating characteristics curves were used to derive guidelines to optimize accuracy of assignment to classes at CBT midtreatment. These findings support the promise of treatment response at CBT midtreatment to identify tailoring variables for use in abbreviating first-stage treatments and facilitating moves to second-stage treatments.
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Affiliation(s)
- Jeremy W Pettit
- a Department of Psychology , Florida International University
| | | | - Yasmin Rey
- a Department of Psychology , Florida International University
| | - Carla Marin
- b Child Study Center , Yale University School of Medicine
| | - James Jaccard
- c Silver School of Social Work , New York University
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Iftene F, Predescu E, Stefan S, David D. Rational-emotive and cognitive-behavior therapy (REBT/CBT) versus pharmacotherapy versus REBT/CBT plus pharmacotherapy in the treatment of major depressive disorder in youth; a randomized clinical trial. Psychiatry Res 2015; 225:687-94. [PMID: 25500320 DOI: 10.1016/j.psychres.2014.11.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 10/27/2014] [Accepted: 11/12/2014] [Indexed: 01/22/2023]
Abstract
Major depressive disorder is a highly prevalent and debilitating condition in youth, so developing efficient treatments is a priority for mental health professionals. Psychotherapy (i.e., cognitive behavioral therapy/CBT), pharmacotherapy (i.e., SSRI medication), and their combination have been shown to be effective in treating youth depression; however, the results are still mixed and there are few studies engaging multi-level analyses (i.e., subjective, cognitive, and biological). Therefore, the aims of this randomized control study (RCT) were both theoretical - integrating psychological and biological markers of depression in a multi-level outcome analysis - and practical - testing the generalizability of previous results on depressed Romanian youth population. Eighty-eight (N=88) depressed Romanian youths were randomly allocated to one of the three treatment arms: group Rational Emotive Behavior Therapy (REBT)/CBT (i.e., a form of CBT), pharmacotherapy (i.e., sertraline), and group REBT/CBT plus pharmacotherapy. The results showed that all outcomes (i.e., subjective, cognitive, and biological) significantly change from pre to post-treatment under all treatment conditions at a similar rate and there were no significant differences among conditions at post-test. In case of categorical analysis of the clinical response rate, we found a non-significant trend favoring group REBT/CBT therapy. Results of analyses concerning outcome interrelations are discussed.
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Affiliation(s)
- Felicia Iftene
- Department of Psychiatry, Queens University, C/o Providence Care Mental Health Services, 752 King Street West, Kingston, Ontario, Canada K7L 4X3.
| | - Elena Predescu
- Department of Neuroscience, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.
| | - Simona Stefan
- Department of Clinical Psychology and Psychotherapy/International Institute for the Advanced Study of Psychotherapy and Applied Mental Health, Babeş-Bolyai University, No 37 Republici Street, 400015 Cluj-Napoca, Romania.
| | - Daniel David
- Department of Clinical Psychology and Psychotherapy/International Institute for the Advanced Study of Psychotherapy and Applied Mental Health, Babeş-Bolyai University, No 37 Republici Street, 400015 Cluj-Napoca, Romania.
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Treatment moderators of child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder. J Am Acad Child Adolesc Psychiatry 2015; 54:116-25. [PMID: 25617252 PMCID: PMC4306810 DOI: 10.1016/j.jaac.2014.11.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Prior work has demonstrated the efficacy of child- and family-focused cognitive-behavioral therapy (CFF-CBT) versus enhanced treatment as usual (TAU; unstructured psychotherapy) for pediatric bipolar disorder (PBD). The current study builds on primary findings by examining baseline child, parent, and family characteristics as moderators of symptom response trajectories. METHOD A total of 69 youth aged 7 to 13 years (mean = 9.19 years, SD = 1.61 years) with DSM-IV-TR bipolar I, II, or not otherwise specified (NOS) were randomly assigned, with family members, to CFF-CBT or TAU. Both treatments consisted of 12 weekly sessions and 6 monthly booster sessions. Participants were assessed at baseline, 4, 8, and 12 weeks, and 6-month follow-up on mania and depression symptoms and overall psychiatric severity. Parents and youth also provided self-report data on baseline characteristics. RESULTS CFF-CBT demonstrated greater efficacy for youth depressive symptoms relative to TAU for parents with higher baseline depressive symptoms and lower income, and marginally for families with higher cohesion. In addition, youth with lower baseline depression and youth with higher self-esteem showed a poorer response to TAU versus CFF-CBT on mania symptom outcomes. Age, sex, baseline mania symptoms, comorbidity, and suicidality did not moderate treatment response. CONCLUSION Results indicate that CFF-CBT was relatively immune to the presence of treatment moderators. Findings suggest the need for specialized treatment to address symptoms of PBD in the context of parental symptomatology and financial stress.
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71
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Cox GR, Callahan P, Churchill R, Hunot V, Merry SN, Parker AG, Hetrick SE. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database Syst Rev 2014; 2014:CD008324. [PMID: 25433518 PMCID: PMC8556660 DOI: 10.1002/14651858.cd008324.pub3] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Depressive disorders are common in children and adolescents and, if left untreated, are likely to recur in adulthood. Depression is highly debilitating, affecting psychosocial, family and academic functioning. OBJECTIVES To evaluate the effectiveness of psychological therapies and antidepressant medication, alone and in combination, for the treatment of depressive disorder in children and adolescents. We have examined clinical outcomes including remission, clinician and self reported depression measures, and suicide-related outcomes. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to 11 June 2014. The register contains reports of relevant randomised controlled trials (RCTs) from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). SELECTION CRITERIA RCTs were eligible for inclusion if they compared i) any psychological therapy with any antidepressant medication, or ii) a combination of psychological therapy and antidepressant medication with a psychological therapy alone, or an antidepressant medication alone, or iii) a combination of psychological therapy and antidepressant medication with a placebo or'treatment as usual', or (iv) a combination of psychological therapy and antidepressant medication with a psychological therapy or antidepressant medication plus a placebo.We included studies if they involved participants aged between 6 and 18 years, diagnosed by a clinician as having Major Depressive Disorder (MDD) based on Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) criteria. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed the quality of the studies. We applied a random-effects meta-analysis, using the odds ratio (OR) to describe dichotomous outcomes, mean difference (MD) to describe continuous outcomes when the same measures were used, and standard mean difference (SMD) when outcomes were measured on different scales. MAIN RESULTS We included eleven studies, involving 1307 participants in this review. We also identified one ongoing study, and two additional ongoing studies that may be eligible for inclusion. Studies recruited participants with different severities of disorder and with a variety of comorbid disorders, including anxiety and substance use disorder, therefore limiting the comparability of the results. Regarding the risk of bias in studies, just under half the studies had adequate allocation concealment (there was insufficient information to determine allocation concealment in the remainder), outcome assessors were blind to the participants' intervention in six studies, and in general, studies reported on incomplete data analysis methods, mainly using intention-to-treat (ITT) analyses. For the majority of outcomes there were no statistically significant differences between the interventions compared. There was limited evidence (based on two studies involving 220 participants) that antidepressant medication was more effective than psychotherapy on measures of clinician defined remission immediately post-intervention (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.27 to 0.98), with 67.8% of participants in the medication group and 53.7% in the psychotherapy group rated as being in remission. There was limited evidence (based on three studies involving 378 participants) that combination therapy was more effective than antidepressant medication alone in achieving higher remission from a depressive episode immediately post-intervention (OR 1.56, 95% CI 0.98 to 2.47), with 65.9% of participants treated with combination therapy and 57.8% of participants treated with medication, rated as being in remission. There was no evidence to suggest that combination therapy was more effective than psychological therapy alone, based on clinician rated remission immediately post-intervention (OR 1.82, 95% CI 0.38 to 8.68).Suicide-related Serious Adverse Events (SAEs) were reported in various ways across studies and could not be combined in meta-analyses. However, some trials measured suicidal ideation using standardised assessment tools suitable for meta-analysis. In one study involving 188 participants, rates of suicidal ideation were significantly higher in the antidepressant medication group (18.6%) compared with the psychological therapy group (5.4%) (OR 0.26, 95% CI 0.09 to 0.72) and this effect appeared to remain at six to nine months (OR 0.26, 95% CI 0.07 to 0.98), with 13.6% of participants in the medication group and 3.9% of participants in the psychological therapy group reporting suicidal ideation. It was unclear what the effect of combination therapy was compared with either antidepressant medication alone or psychological therapy alone on rates of suicidal ideation. The impact of any of the assigned treatment packages on drop out was also mostly unclear across the various comparisons in the review.Limited data and conflicting results based on other outcome measures make it difficult to draw conclusions regarding the effectiveness of any specific intervention based on these outcomes. AUTHORS' CONCLUSIONS There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered RCTs are required.
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Affiliation(s)
- Georgina R Cox
- University of MelbourneOrygen Youth Health Research Centre, Centre for Youth Mental HealthLocked Bag 10, 35 Poplar RoadParkvilleMelbourneVictoriaAustralia3054
| | - Patch Callahan
- University of MelbourneOrygen Youth Health Research Centre, Centre for Youth Mental HealthLocked Bag 10, 35 Poplar RoadParkvilleMelbourneVictoriaAustralia3054
| | - Rachel Churchill
- University of BristolCentre for Academic Mental Health, School of Social and Community MedicineOakfield HouseOakfield GroveBristolUKBS8 2BN
| | - Vivien Hunot
- University of BristolCentre for Academic Mental Health, School of Social and Community MedicineOakfield HouseOakfield GroveBristolUKBS8 2BN
| | - Sally N Merry
- University of AucklandDepartment of Psychological MedicinePrivate Bag 92019AucklandNew Zealand
| | - Alexandra G Parker
- University of MelbourneOrygen Youth Health Research Centre, Centre for Youth Mental HealthLocked Bag 10, 35 Poplar RoadParkvilleMelbourneVictoriaAustralia3054
| | - Sarah E Hetrick
- University of MelbourneOrygen Youth Health Research Centre, Centre for Youth Mental HealthLocked Bag 10, 35 Poplar RoadParkvilleMelbourneVictoriaAustralia3054
- University of Melbourneheadspace Centre of Excellence, Centre for Youth Mental HealthMelbourneVictoriaAustralia
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72
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Abstract
Depression is a relatively common diagnosis in children and adolescents, and is associated with significant morbidity and suicidality in this population. Evidence-based treatment of the acute illness is imperative to try to prevent the development of treatment-resistant depression or other complications. In situations where response to acute treatment is inadequate, clinicians should first consider factors that may influence outcome, such as psychiatric or medical comorbidities, psychosocial stressors, and treatment noncompliance. Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for depression in children and adolescents. For treatment-resistant depression, a switch to an alternate SSRI is recommended before trials of other antidepressants. Psychotherapy, such as cognitive behavioral therapy or interpersonal therapy, may improve treatment response. More research is needed examining medication augmentation strategies for treatment-resistant depression in children and adolescents.
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Affiliation(s)
- Melissa DeFilippis
- Department of Child and Adolescent Psychiatry, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555-0188, USA,
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Isa A, Bernstein I, Trivedi M, Mayes T, Kennard B, Emslie G. Childhood depression subscales using repeated sessions on Children's Depression Rating Scale - revised (CDRS-R) scores. J Child Adolesc Psychopharmacol 2014; 24:318-24. [PMID: 25137188 PMCID: PMC4137336 DOI: 10.1089/cap.2013.0127] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Although acute treatments have been shown to be effective in treating early-onset depression, only one-third or thereabouts reach a remission within 3 months. Unfortunately, delayed time to remission in early-onset depression leads to poorer therapeutic outcomes. Clearly, there is a need to identify, diagnose, and provide effective treatment of a depressed patient quickly. A sophisticated understanding of depression subscales and their change over time with treatment could enhance pathways to individualized treatment approaches for childhood depression. OBJECTIVE Previous studies have found that the clinician-measured instrument, Children's Depression Rating Scale-Revised (CDRS-R) measures multiple subscales (or components) of depression. The aim of this study was to see how these subscales may change over the course of a 12-week study. This knowledge will help determine if dimensions/subscales of childhood depression (paralleling the adult literature) using the subscales derived from factor analysis procedure is useful. METHODS We examined two clinical trials in which youth (n=234) with major depressive disorder (MDD) were treated openly with fluoxetine for eight sessions spread over 12 weeks. The CDRS-R was completed based on clinician interviews with parent and child at each session. Classical test theory and component analysis with associated parallel analysis (oblique rotation) were conducted on each week's scores. RESULTS Although more factors were needed for the baseline and first two therapy sessions, a two-factor solution sufficed thereafter. Depressed facial affect, listless speech, and hypoactivity best defined Factor I, whereas sleep problems, appetite disturbance, physical symptoms, irritability, guilt, and weeping best defined Factor II. All other symptoms cross-loaded almost equally on the two factors. The scale's reliability (internal consistency) improved from baseline to exit sessions (α=0.65-0.91). As a result, the clinicians' assessments of the various symptoms became more highly related to one another. This caused the first eigenvalue to increase from 3.24 to 7.38 and the variance explained to increase (%) from 19% to 43% over sessions. These two factors may reflect 1) clinician-observed signs and 2) reported symptoms of depression. CONCLUSIONS Factor analysis of CDRS-R data in a single session consistently generates a complex and difficult to interpret structure of at least three factors. This makes it very difficult to understand what these factors measure. However, when gathered over additional sessions, the CDRS-R structure tends to simplify to two factors. The reasons for this simplification are as yet unclear and in need of further study.
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Affiliation(s)
- Ameena Isa
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas Texas
| | - Ira Bernstein
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas Texas
| | - Madhukar Trivedi
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas Texas
| | - Taryn Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas Texas.,Division of Child and Adolescent Psychiatry, Children's Medical Center, Dallas Texas
| | - Betsy Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas Texas.,Division of Child and Adolescent Psychiatry, Children's Medical Center, Dallas Texas
| | - Graham Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas Texas.,Division of Child and Adolescent Psychiatry, Children's Medical Center, Dallas Texas
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74
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Gordon M, Melvin GA. Prescribing for depressed adolescents: office decision-making in the face of limited research evidence. J Paediatr Child Health 2014; 50:498-503. [PMID: 24617419 DOI: 10.1111/jpc.12517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Michael Gordon
- Child and Adolescent Stream, Early in Life Mental Health Service, Monash Medical Centre, Melbourne, Victoria, Australia
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75
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Dubicka B, Brent D. Combined Therapy in Adolescent Depression. Int J Cogn Ther 2014. [DOI: 10.1521/ijct.2014.7.2.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Curry JF. Future Directions in Research on Psychotherapy for Adolescent Depression. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2014; 43:510-26. [DOI: 10.1080/15374416.2014.904233] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Andrews JT, Seide M, Guarda AS, Redgrave GW, Coffey DBJ. Electroconvulsive therapy in an adolescent with severe major depression and anorexia nervosa. J Child Adolesc Psychopharmacol 2014; 24:94-8. [PMID: 24679175 DOI: 10.1089/cap.2014.2422] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Joseph T Andrews
- 1 Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine , Baltimore, Maryland
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78
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Piacentini J, Bennett S, Compton S, Kendall P, Birmaher B, Albano AM, March J, Sherrill J, Sakolsky D, Ginsburg G, Rynn M, Bergman RL, Gosch E, Waslick B, Iyengar S, McCracken J, Walkup J. 24- and 36-week outcomes for the Child/Adolescent Anxiety Multimodal Study (CAMS). J Am Acad Child Adolesc Psychiatry 2014; 53:297-310. [PMID: 24565357 PMCID: PMC3982864 DOI: 10.1016/j.jaac.2013.11.010] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 11/06/2013] [Accepted: 11/26/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We report active treatment group differences on response and remission rates and changes in anxiety severity at weeks 24 and 36 for the Child/Adolescent Anxiety Multimodal Study (CAMS). METHOD CAMS youth (N = 488; 74% ≤ 12 years of age) with DSM-IV separation, generalized, or social anxiety disorder were randomized to 12 weeks of cognitive-behavioral therapy (CBT), sertraline (SRT), CBT+SRT (COMB), or medication management/pill placebo (PBO). Responders attended 6 monthly booster sessions in their assigned treatment arm; youth in COMB and SRT continued on their medication throughout this period. Efficacy of COMB, SRT, and CBT (n = 412) was assessed at 24 and 36 weeks postrandomization. Youth randomized to PBO (n = 76) were offered active CAMS treatment if nonresponsive at week 12 or over follow-up and were not included here. Independent evaluators blind to study condition assessed anxiety severity, functioning, and treatment response. Concomitant treatments were allowed but monitored over follow-up. RESULTS The majority (>80%) of acute responders maintained positive response at both weeks 24 and 36. Consistent with acute outcomes, COMB maintained advantage over CBT and SRT, which did not differ, on dimensional outcomes; the 3 treatments did not differ on most categorical outcomes over follow-up. Compared to COMB and CBT, youth in SRT obtained more concomitant psychosocial treatments, whereas those in SRT and CBT obtained more concomitant combined (medication plus psychosocial) treatment. CONCLUSIONS COMB maintained advantage over CBT and SRT on some measures over follow-up, whereas the 2 monotherapies remained indistinguishable. The observed convergence of COMB and monotherapy may be related to greater use of concomitant treatment during follow-up among youth receiving the monotherapies, although other explanations are possible. Although outcomes were variable, most CAMS-treated youth experienced sustained treatment benefit. Clinical trial registration information-Child and Adolescent Anxiety Disorders (CAMS); URL: http://clinicaltrials.gov. Unique identifier: NCT00052078.
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Affiliation(s)
- John Piacentini
- University of California-Los Angeles (UCLA) Semel Institute for Neuroscience and Human Behavior.
| | | | | | | | - Boris Birmaher
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center
| | - Anne Marie Albano
- New York State Psychiatric Institute–Columbia University Medical Center
| | | | - Joel Sherrill
- Division of Services and Intervention Research, National Institute of Mental Health (NIMH)
| | - Dara Sakolsky
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center
| | | | - Moira Rynn
- New York State Psychiatric Institute–Columbia University Medical Center
| | - R. Lindsey Bergman
- University of California–Los Angeles (UCLA) Semel Institute for Neuroscience and Human Behavior
| | | | | | - Satish Iyengar
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center
| | - James McCracken
- University of California–Los Angeles (UCLA) Semel Institute for Neuroscience and Human Behavior
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Elevated morning cortisol is a stratified population-level biomarker for major depression in boys only with high depressive symptoms. Proc Natl Acad Sci U S A 2014; 111:3638-43. [PMID: 24550453 DOI: 10.1073/pnas.1318786111] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Major depressive disorder (MD) is a debilitating public mental health problem with severe societal and personal costs attached. Around one in six people will suffer from this complex disorder at some point in their lives, which has shown considerable etiological and clinical heterogeneity. Overall there remain no validated biomarkers in the youth population at large that can aid the detection of at-risk groups for depression in general and for boys and young men in particular. Using repeated measurements of two well-known correlates of MD (self-reported current depressive symptoms and early-morning cortisol), we undertook a population-based investigation to ascertain subtypes of adolescents that represent separate longitudinal phenotypes. Subsequently, we tested for differential risks for MD and other mental illnesses and cognitive differences between subtypes. Through the use of latent class analysis, we revealed a high-risk subtype (17% of the sample) demarcated by both high depressive symptoms and elevated cortisol levels. Membership of this class of individuals was associated with increased levels of impaired autobiographical memory recall in both sexes and the greatest likelihood of experiencing MD in boys only. These previously unidentified findings demonstrate at the population level a class of adolescents with a common physiological biomarker specifically for MD in boys and for a mnemonic vulnerability in both sexes. We suggest that the biobehavioral combination of high depressive symptoms and elevated morning cortisol is particularly hazardous for adolescent boys.
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Parise EM, Alcantara LF, Warren BL, Wright KN, Hadad R, Sial OK, Kroeck KG, Iñiguez SD, Bolaños-Guzmán CA. Repeated ketamine exposure induces an enduring resilient phenotype in adolescent and adult rats. Biol Psychiatry 2013; 74:750-9. [PMID: 23790225 PMCID: PMC3785550 DOI: 10.1016/j.biopsych.2013.04.027] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 04/10/2013] [Accepted: 04/27/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Major depressive disorder afflicts up to 10% of adolescents. However, nearly 50% of those afflicted are considered nonresponsive to available treatments. Ketamine, a noncompetitive N-methyl-D-aspartate receptor antagonist has shown potential as a rapid-acting and long-lasting treatment for major depressive disorder in adults. Thus, the effectiveness and functional consequences of ketamine exposure during adolescence were explored. METHODS Adolescent male rats (postnatal day [PD] 35) received two ketamine (0, 5, 10, or 20 mg/kg) injections, 4 hours apart, after exposure to day 1 of the forced swim test (FST). The next day, rats were reexposed to the FST to assess ketamine-induced antidepressant-like responses. Separate groups were exposed to chronic unpredictable stress to confirm findings from the FST. After these initial experiments, adolescent naive rats were exposed to either 1 or 15 consecutive days (PD35-49) of ketamine (20 mg/kg) twice daily. Ketamine's influence on behavioral reactivity to rewarding (i.e., sucrose preference) and aversive (i.e., elevated plus-maze, FST) circumstances was then assessed 2 months after treatment. To control for age-dependent effects, adult rats (PD75-89) were exposed to identical experimental conditions. RESULTS Ketamine (20 mg/kg) reversed the chronic unpredictable stress-induced depression-like behaviors in the FST. Repeated ketamine exposure resulted in anxiolytic- and antidepressant-like responses 2 months after drug exposure. None of the ketamine doses used were capable of inducing drug-seeking behaviors as measured by place preference conditioning. CONCLUSIONS Repeated ketamine exposure induces enduring resilient-like responses regardless of age of exposure. These findings point to ketamine, and its repeated exposure, as a potentially useful antidepressant during adolescence.
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Affiliation(s)
- Eric M. Parise
- Department of Psychology and Program in Neuroscience, Florida State University, Tallahassee, FL
| | - Lyonna F. Alcantara
- Department of Psychology and Program in Neuroscience, Florida State University, Tallahassee, FL
| | - Brandon L. Warren
- Department of Psychology and Program in Neuroscience, Florida State University, Tallahassee, FL
| | - Katherine N. Wright
- Department of Psychology and Program in Neuroscience, Florida State University, Tallahassee, FL
| | - Roey Hadad
- Department of Psychology and Program in Neuroscience, Florida State University, Tallahassee, FL
| | - Omar K. Sial
- Department of Psychology and Program in Neuroscience, Florida State University, Tallahassee, FL
| | - Kyle G. Kroeck
- Department of Psychology and Program in Neuroscience, Florida State University, Tallahassee, FL
| | - Sergio D. Iñiguez
- Department of Psychology and Program in Neuroscience, Florida State University, Tallahassee, FL
| | - Carlos A. Bolaños-Guzmán
- Department of Psychology and Program in Neuroscience, Florida State University, Tallahassee, FL
- Corresponding author: Dr. CA Bolaños-Guzmán Department of Psychology and Program in Neuroscience, Florida State University, 1107 West Call Street, Tallahassee, FL 32306-4301. Tel: (850) 644-2627; Fax (850) 645-7518;
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Mansoor B, Rengasamy M, Hilton R, Porta G, He J, Spirito A, Emslie GJ, Mayes TL, Clarke G, Wagner KD, Shamseddeen W, Birmaher B, Ryan N, Brent D. The bidirectional relationship between body mass index and treatment outcome in adolescents with treatment-resistant depression. J Child Adolesc Psychopharmacol 2013; 23:458-67. [PMID: 24024532 PMCID: PMC3779018 DOI: 10.1089/cap.2012.0095] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Depression and obesity are associated, but the impact of obesity on depression treatment outcome, or, conversely, the impact of treatment on body mass index (BMI) in depressed adolescents has not been reported. In this article, we examine the bidirectional relationships between BMI and treatment response in adolescents with treatment-resistant depression. METHOD Participants in the Treatment of Selective Serotonin Reuptake Inhibitor (SSRI) Resistant Depression in Adolescents (TORDIA) study had height and weight assessed at baseline, weekly for the first 6 weeks, biweekly for the next 6 weeks, and monthly from weeks 12 through 24. The impact of baseline BMI as a predictor and moderator of treatment response was assessed. In addition, participants' changes in BMI were assessed as a function of specific treatment assignment and treatment response. RESULTS Participants assigned to SSRIs had a greater increase in BMI-for-age-sex z-score and weight than did those assigned to venlafaxine. Post-hoc, those treated with paroxetine or citalopram had the biggest increases in BMI, relative to fluoxetine or venlafaxine. Overweight or obesity was neither a predictor nor a moderator of treatment outcome, nor of subsequent BMI change. CONCLUSIONS Overweight status does not appear to affect treatment response in adolescents with resistant depression. The successful treatment of depression does not appear to favorably affect weight or BMI. Fluoxetine and venlafaxine are less likely to cause an increase in BMI than paroxetine or citalopram.
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Affiliation(s)
- Brandon Mansoor
- Wayne State University School of Medicine, Detroit, Michigan
| | | | - Robert Hilton
- Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Giovanna Porta
- Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
| | - Jiayan He
- The Cleveland Clinic, Cleveland, Ohio
| | - Anthony Spirito
- Department of Psychiatry and Human Behavior, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Taryn L. Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gregory Clarke
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Karen Dineen Wagner
- Department of Psychiatry, University of Texas Medical Branch at Galveston, Galveston, Texas
| | - Wael Shamseddeen
- Department of Psychiatry, Rosalind Franklin University, North Chicago, Illinois
| | - Boris Birmaher
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Neal Ryan
- Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
| | - David Brent
- Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
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Sparks JA, Duncan BL. Outside the Black Box: Re-assessing Pediatric Antidepressant Prescription. JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY = JOURNAL DE L'ACADEMIE CANADIENNE DE PSYCHIATRIE DE L'ENFANT ET DE L'ADOLESCENT 2013; 22:240-246. [PMID: 23970915 PMCID: PMC3749900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 05/13/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE The purpose of this review is to assess whether evidence supports a favorable risk/benefit profile for pediatric antidepressant use and reconsideration of the black box. METHOD The review examines studies post-black box purporting to show declines in pediatric antidepressant use and rising youth suicide, summarizes evidence for efficacy and safety of pediatric antidepressants, and discusses irregularities in recent meta-analyses of fluoxetine for youth. RESULTS Pediatric antidepressant prescription did not significantly decline post-black box and youth suicide has risen only in recent years. Recent meta-analyses fail to undermine evidence that antidepressants are associated with increased risk of suicidality in youth. CONCLUSIONS First line prescription of antidepressants for youth is not advisable. The black box and international warnings on pediatric use of antidepressants are warranted. Wider availability of psychosocial options for depressed youth is recommended.
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Affiliation(s)
| | - Barry L. Duncan
- Heart and Soul of Change Project, Jensen Beach, Florida, USA
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83
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MacPherson HA, Algorta GP, Mendenhall AN, Fields BW, Fristad MA. Predictors and moderators in the randomized trial of multifamily psychoeducational psychotherapy for childhood mood disorders. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2013; 43:459-72. [PMID: 23795823 DOI: 10.1080/15374416.2013.807735] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study investigated predictors and moderators of mood symptoms in the randomized controlled trial (RCT) of Multi-Family Psychoeducational Psychotherapy (MF-PEP) for childhood mood disorders. Based on predictors and moderators in RCTs of psychosocial interventions for adolescent mood disorders, we hypothesized that children's greater functional impairment would predict worse outcome, whereas children's stress/trauma history and parental expressed emotion and psychopathology would moderate outcome. Exploratory analyses examined other demographic, functioning, and diagnostic variables. Logistic regression and linear mixed effects modeling were used in this secondary analysis of the MF-PEP RCT of 165 children, ages 8 to 12, with mood disorders, a majority of whom were male (73%) and White, non-Hispanic (90%). Treatment nonresponse was significantly associated with higher baseline levels of global functioning (i.e., less impairment; Cohen's d = 0.51) and lower levels of stress/trauma history (d = 0.56) in children and Cluster B personality disorder symptoms in parents (d = 0.49). Regarding moderators, children with moderately impaired functioning who received MF-PEP had significantly decreased mood symptoms (t = 2.10, d = 0.33) compared with waitlist control. MF-PEP had the strongest effect on severely impaired children (t = 3.03, d = 0.47). Comprehensive assessment of demographic, youth, parent, and familial variables should precede intervention. Treatment of mood disorders in high-functioning youth without stress/trauma histories and with parents with elevated Cluster B symptoms may require extra therapeutic effort, whereas severely impaired children may benefit most from MF-PEP.
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84
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Impact of treatments for depression on comorbid anxiety, attentional, and behavioral symptoms in adolescents with selective serotonin reuptake inhibitor-resistant depression. J Am Acad Child Adolesc Psychiatry 2013; 52:482-92. [PMID: 23622849 PMCID: PMC3756470 DOI: 10.1016/j.jaac.2013.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 02/26/2013] [Accepted: 02/28/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the relative efficacy of antidepressant medication, alone and in combination with cognitive behavioral therapy (CBT), on comorbid symptoms of anxiety, attention, and disruptive behavior disorders in participants in the Treatment of Resistant Depression in Adolescents (TORDIA) trial. METHOD Adolescents with selective serotonin reuptake inhibitor (SSRI)-resistant depression (N = 334) were randomly assigned to a medication switch alone (to another SSRI or to venlafaxine) or to a medication switch plus CBT. Anxiety, attention-deficit/hyperactivity disorder (ADHD), and disruptive behavior disorder (DBD) symptoms were assessed by psychiatric interview and self-report at regular intervals between baseline and 24 weeks. The differential effects of medication and of CBT, and the impact of remission on the course of comorbid symptoms and diagnoses, were assessed using generalized linear mixed models. RESULTS Remission was associated with a greater reduction in scalar measures of anxiety, ADHD, and DBDs, and a greater decrease in the rate of diagnosed anxiety disorders. The correlations between the changes in symptoms of depression on the CDRS-R and anxiety, ADHD, and oppositional symptoms were modest, ranging from r = 0.12 to r = 0.28. There were no significant differential treatment effects on diagnoses, or corresponding symptoms. CONCLUSION The achievement of remission had a beneficial effect on anxiety, ADHD, and DBD symptoms, regardless of the type of treatment received. There were no differential effects of medication or CBT on outcome, except for a nonsignificant trend that those adolescents treated with SSRIs showed a greater decrease in rates of comorbid DBDs relative to those treated with venlafaxine. Clinical trial registration information-Treatment of SSRI-Resistant Depression In Adolescents (TORDIA); http://clinicaltrials.gov/; NCT00018902.
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85
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Cox GR, Callahan P, Churchill R, Hunot V, Merry SN, Parker AG, Hetrick SE. Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents. Cochrane Database Syst Rev 2012; 11:CD008324. [PMID: 23152255 DOI: 10.1002/14651858.cd008324.pub2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Depressive disorders are common in children and adolescents and, if left untreated, are likely to recur in adulthood. Depression is highly debilitating, affecting psychosocial, family and academic functioning. OBJECTIVES To evaluate the effectiveness of psychological therapies and antidepressant medication, alone and in combination, for the treatment of depressive disorder in children and adolescents. We have examined clinical outcomes including remission, clinician and self reported depression measures, and suicide-related outcomes. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to 11 November 2011. This register contains reports of relevant randomised controlled trials (RCTs) from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). SELECTION CRITERIA RCTs were eligible for inclusion if they compared i) any psychological therapy with any antidepressant medication, or ii) a combination of psychological therapy and antidepressant medication with a psychological therapy alone, or an antidepressant medication alone, or iii) a combination of psychological therapy and antidepressant medication with a placebo or 'treatment as usual', or (iv) a combination of psychological therapy and antidepressant medication with a psychological therapy or antidepressant medication plus a placebo.We included studies if they involved participants aged between 6 and 18 years, diagnosed by a clinician as having Major Depressive Disorder (MDD) based on Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) criteria. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed the quality of the studies. We applied a random-effects meta-analysis, using the odds ratio (OR) to describe dichotomous outcomes, mean difference (MD) to describe continuous outcomes when the same measures were used, and standard mean difference (SMD) when outcomes were measured on different scales. MAIN RESULTS We included ten studies, involving 1235 participants in this review. Studies recruited participants with different severities of disorder and with a variety of comorbid disorders, including anxiety and substance use disorder, therefore limiting the comparability of the results. Regarding the risk of bias in studies, half the studies had adequate allocation concealment (there was insufficient information to determine allocation concealment in the remainder), outcome assessors were blind to the participants' intervention in six studies, and in general, studies reported on incomplete data analysis methods, mainly using intention-to-treat (ITT) analyses. For the majority of outcomes there were no statistically significant differences between the interventions compared. There was limited evidence (based on two studies involving 220 participants) that antidepressant medication was more effective than psychotherapy on measures of clinician defined remission immediately post-intervention (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.27 to 0.98), with 67.8% of participants in the medication group and 53.7% in the psychotherapy group rated as being in remission. There was limited evidence (based on three studies involving 378 participants) that combination therapy was more effective than antidepressant medication alone in achieving higher remission from a depressive episode immediately post-intervention (OR 1.56, 95% CI 0.98 to 2.47), with 65.9% of participants treated with combination therapy and 57.8% of participants treated with medication, rated as being in remission. There was no evidence to suggest that combination therapy was more effective than psychological therapy alone, based on clinician rated remission immediately post-intervention (OR 1.82, 95% CI 0.38 to 8.68).Suicide-related Serious Adverse Events (SAEs) were reported in various ways across studies and could not be combined in meta-analyses. However suicidal ideation specifically was generally measured and reported using standardised assessment tools suitable for meta-analysis. In one study involving 188 participants, rates of suicidal ideation were significantly higher in the antidepressant medication group (18.6%) compared with the psychological therapy group (5.4%) (OR 0.26, 95% CI 0.09 to 0.72) and this effect appeared to remain at six to nine months (OR 1.27, 95% CI 0.68 to 2.36), with 13.6% of participants in the medication group and 3.9% of participants in the psychological therapy group reporting suicidal ideation. It was unclear what the effect of combination therapy was compared with either antidepressant medication alone or psychological therapy alone on rates of suicidal ideation. The impact of any of the assigned treatment packages on drop out was also mostly unclear across the various comparisons in the review.Limited data and conflicting results based on other outcome measures make it difficult to draw conclusions regarding the effectiveness of any specific intervention based on these outcomes. AUTHORS' CONCLUSIONS There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered RCTs are required.
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Affiliation(s)
- Georgina R Cox
- Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia.
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86
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Cox GR, Fisher CA, De Silva S, Phelan M, Akinwale OP, Simmons MB, Hetrick SE. Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents. Cochrane Database Syst Rev 2012; 11:CD007504. [PMID: 23152246 PMCID: PMC8978530 DOI: 10.1002/14651858.cd007504.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Depressive disorders often begin during childhood or adolescence. There is a growing body of evidence supporting effective treatments during the acute phase of a depressive disorder. However, little is known about treatments for preventing relapse or recurrence of depression once an individual has achieved remission or recovery from their symptoms. OBJECTIVES To determine the efficacy of early interventions, including psychological and pharmacological interventions, to prevent relapse or recurrence of depressive disorders in children and adolescents. SEARCH METHODS We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 1 June 2011). The CCDANCTR contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). In addition we handsearched the references of all included studies and review articles. SELECTION CRITERIA Randomised controlled trials using a psychological or pharmacological intervention, with the aim of preventing relapse or recurrence from an episode of major depressive disorder (MDD) or dysthymic disorder (DD) in children and adolescents were included. Participants were required to have been diagnosed with MDD or DD according to DSM or ICD criteria, using a standardised and validated assessment tool. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all trials for inclusion in the review, extracted trial and outcome data, and assessed trial quality. Results for dichotomous outcomes are expressed as odds ratio and continuous measures as mean difference or standardised mean difference. We combined results using random-effects meta-analyses, with 95% confidence intervals. We contacted lead authors of included trials and requested additional data where possible. MAIN RESULTS Nine trials with 882 participants were included in the review. In five trials the outcome assessors were blind to the participants' intervention condition and in the remainder of trials it was unclear. In the majority of trials, participants were either not blind to their intervention condition, or it was unclear whether they were or not. Allocation concealment was also unclear in the majority of trials. Although all trials treated participants in an outpatient setting, the designs implemented in trials was diverse, which limits the generalisability of the results. Three trials indicated participants treated with antidepressant medication had lower relapse-recurrence rates (40.9%) compared to those treated with placebo (66.6%) during a relapse prevention phase (odds ratio (OR) 0.34; 95% confidence interval (CI) 0.18 to 0.64, P = 0.02). One trial that compared a combination of psychological therapy and medication to medication alone favoured a combination approach over medication alone, however this result did not reach statistical significance (OR 0.26; 95% CI 0.06 to 1.15). The majority of trials that involved antidepressant medication reported adverse events including suicide-related behaviours. However, there were not enough data to show which treatment approach results in the most favourable adverse event profile. AUTHORS' CONCLUSIONS Currently, there is little evidence to conclude which type of treatment approach is most effective in preventing relapse or recurrence of depressive episodes in children and adolescents. Limited trials found that antidepressant medication reduces the chance of relapse-recurrence in the future, however, there is considerable diversity in the design of trials, making it difficult to compare outcomes across studies. Some of the research involving psychological therapies is encouraging, however at present more trials with larger sample sizes need to be conducted in order to explore this treatment approach further.
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Affiliation(s)
- Georgina R Cox
- Orygen YouthHealth ResearchCentre,Centre for YouthMentalHealth,University ofMelbourne,Melbourne, Australia.
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87
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Plener PL, Fegert JM, Kölch MG. Psychopharmakologische Behandlung von Depressionen im Kindes- und Jugendalter. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2012; 40:365-71. [DOI: 10.1024/1422-4917/a000196] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Die psychopharmakologische Behandlung kann – je nach Schweregrad- eine wichtige Option in der Therapie depressiver Erkrankungen bei Kindern und Jugendlichen darstellen. Diese Überblicksarbeit gibt klinische Behandlungsempfehlungen mit einem Fokus auf den Umgang mit Suizidalität und therapieresistenten Patienten. Die Studienlage zur medikamentösen Therapie der depressiven Erkrankung im Kindes- und Jugendalter hat sich seit den Warnungen der amerikanischen Zulassungsbehörde zum Auftreten von Suizidalität unter Therapie mit Selektiven Serotonin Wiederaufnahmehemmern (SSRIs) deutlich verbessert. In der Versorgung von depressiven Kindern und Jugendlichen ist in den letzten Jahren in Deutschland ein Trend hin zu einer evidenzbasierten psychopharmakologischen Therapie zu erkennen.
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Affiliation(s)
- Paul L. Plener
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm
| | - Jörg M. Fegert
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm
| | - Michael G. Kölch
- Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Universität Ulm
- Kliniken für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik, Vivantes Netzwerk für Gesundheit GmbH, Berlin
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Abstract
This article reviews the assessment and treatment for depression in children and adolescents, emphasizing the implementation of evidence-based treatments into clinical care. Past trials of antidepressant medications are reviewed, as well as the clinical use of antidepressants and pharmacologic strategies for refractory illness or in the context of comorbid conditions. Clinicians who treat youth now have a body of empiric research to help guide treatment decisions; however, personalized treatment based on associated symptoms, comorbid conditions, contextual factors, and psychiatric history is essential. Further research is needed in the pharmacologic treatment of depressed youth, including expanding the study of non-SSRI antidepressants, augmentation and adjunctive strategies, and treatment in patients with comorbid conditions.
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Affiliation(s)
- Christine J Choe
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX 75390-8589, USA.
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89
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Young JF, Makover HB, Cohen JR, Mufson L, Gallop R, Benas JS. Interpersonal psychotherapy-adolescent skills training: anxiety outcomes and impact of comorbidity. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2012; 41:640-53. [PMID: 22891881 PMCID: PMC3448978 DOI: 10.1080/15374416.2012.704843] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Given the frequent comorbidity of anxiety and depression, it is important to study the effects of depression interventions on anxiety and the impact of comorbid anxiety on depression outcomes. This article reports on pooled anxiety and depression data from two randomized trials of Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST), a depression prevention program. Ninety-eight adolescents were randomized to receive IPT-AST or school counseling (SC). Outcome and predictor analyses were performed utilizing hierarchical linear models. IPT-AST adolescents had significantly greater reductions in anxiety and depressive symptoms than SC adolescents during the intervention. Baseline anxiety symptoms predicted change in depressive symptoms for adolescents in both intervention conditions, with adolescents low in baseline anxiety demonstrating more rapid change in depressive symptoms than adolescents high in baseline anxiety. These findings indicate that IPT-AST is effective at decreasing both depressive and anxiety symptoms. For adolescents with comorbid symptoms of anxiety, there may be slower rates of change in depressive symptoms following prevention programs.
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Affiliation(s)
- Jami F. Young
- Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers University
| | - Heather B. Makover
- Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers University
| | | | - Laura Mufson
- Department of Psychiatry, Columbia University College of Physicians and Surgeons and New York State Psychiatric Institute
| | - Robert Gallop
- Department of Mathematics, Applied Statistics Program, West Chester University
| | - Jessica S. Benas
- Department of Clinical Psychology, Graduate School of Applied and Professional Psychology, Rutgers University
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90
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Czaja AS, Valuck R. Off-label antidepressant use in children and adolescents compared with young adults: extent and level of evidence. Pharmacoepidemiol Drug Saf 2012; 21:997-1004. [DOI: 10.1002/pds.3312] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/26/2012] [Accepted: 05/25/2012] [Indexed: 11/07/2022]
Affiliation(s)
- Angela S. Czaja
- Department of Pediatrics; University of Colorado School of Medicine; Aurora CO USA
- Children's Hospital Colorado; Aurora CO USA
| | - Robert Valuck
- Department of Clinical Pharmacy; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora CO USA
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91
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Maalouf FT, Brent DA. Child and adolescent depression intervention overview: what works, for whom and how well? Child Adolesc Psychiatr Clin N Am 2012; 21:299-312, viii. [PMID: 22537728 DOI: 10.1016/j.chc.2012.01.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The authors review the currently available evidence-based treatments of child and adolescent major depressive disorder. Medication monotherapy, namely with selective serotonin reuptake inhibitors, is supported by large clinical trials in adolescents. For mild to moderate depression, cognitive behavior therapy (CBT) and interpersonal therapy are reasonable options as monotherapies. There is also evidence that the combination of medication and CBT is superior to medication alone for accelerating the pace of treatment response and remission, despite some negative studies. Response, remission, and recurrence rates after acute treatment and during long-term follow-ups are also presented and discussed.
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Affiliation(s)
- Fadi T Maalouf
- Department of Psychiatry, American University of Beirut Medical Center, Beirut, Lebanon.
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92
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McMakin DL, Olino TM, Porta G, Dietz LJ, Emslie G, Clarke G, Wagner KD, Asarnow JR, Ryan ND, Birmaher B, Shamseddeen W, Mayes T, Kennard B, Spirito A, Keller M, Lynch FL, Dickerson JF, Brent DA. Anhedonia predicts poorer recovery among youth with selective serotonin reuptake inhibitor treatment-resistant depression. J Am Acad Child Adolesc Psychiatry 2012; 51:404-11. [PMID: 22449646 PMCID: PMC3536476 DOI: 10.1016/j.jaac.2012.01.011] [Citation(s) in RCA: 299] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 01/13/2012] [Accepted: 01/27/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To identify symptom dimensions of depression that predict recovery among selective serotonin reuptake inhibitor (SSRI) treatment-resistant adolescents undergoing second-step treatment. METHOD The Treatment of Resistant Depression in Adolescents (TORDIA) trial included 334 SSRI treatment-resistant youth randomized to a medication switch, or a medication switch plus CBT. This study examined five established symptom dimensions (Child Depression Rating Scale-Revised) at baseline as they predicted recovery over 24 weeks of acute and continuation treatment. The two indices of recovery that were evaluated were time to remission and number of depression-free days. RESULTS Multivariate analyses examining all five depression symptom dimensions simultaneously indicated that anhedonia was the only dimension to predict a longer time to remission, and also the only dimension to predict fewer depression-free days. In addition, when anhedonia and CDRS-total score were evaluated simultaneously, anhedonia continued to uniquely predict longer time to remission and fewer depression-free days. CONCLUSIONS Anhedonia may represent an important negative prognostic indicator among treatment-resistant depressed adolescents. Further research is needed to elucidate neurobehavioral underpinnings of anhedonia, and to test treatments that target anhedonia in the context of overall treatment of depression.
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Maalouf FT, Porta G, Vitiello B, Emslie G, Mayes T, Clarke G, Wagner KD, Asarnow JR, Spirito A, Keller M, Birmaher B, Ryan N, Shamseddeen W, Iyengar S, Brent D. Do sub-syndromal manic symptoms influence outcome in treatment resistant depression in adolescents? A latent class analysis from the TORDIA study. J Affect Disord 2012; 138:86-95. [PMID: 22284022 PMCID: PMC3621087 DOI: 10.1016/j.jad.2011.12.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 12/01/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND To identify distinct depressive symptom trajectories in the TORDIA study and determine their correlates. METHODS Latent Class Growth Analysis (LCGA) using the Children's Depression Rating Scale-Revised (CDRS-R) through 72 weeks from intake. RESULTS 3 classes were identified: (1) little change in symptomatic status ("NO"), comprising 24.9% of participants, with a 72-week remission rate of 25.3%; (2) slow, steady improvement ("SLOW"), comprising 47.9% of participants, with a remission rate of 60.0%, and (3) rapid symptom response ("GO"), comprising 27.2% of participants, with a remission rate of 85.7%. Higher baseline CDRS-R (p<0.001) and poorer functioning (p=0.03) were the strongest discriminators between NO and GO. Higher baseline CDRS (p<0.001) and scores on the Mania Rating Scale (MRS) (p=0.01) were the strongest discriminators between SLOW and GO. Other variables differentiating GO from both NO and from SLOW, were better baseline functioning, lower hopelessness, and lower family conflict. Both NO and SLOW showed increases on the MRS over time compared to GO (ps ≤ 0.04), and increasing MRS was strongly associated with lack of remission by 72 weeks (p=0.02). LIMITATIONS High rate of open treatment by the end of the follow-up period creates difficulty in drawing clear inferences about the long-term impact of initial randomization. CONCLUSION Along with depressive severity, sub-syndromal manic symptoms, at baseline, and over time emerged as important predictors and correlates of poor outcome in this sample. Further research is needed on the treatment of severe depression, and on the assessment and management of sub-syndromal manic symptoms in treatment resistant depression.
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94
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Washburn JJ, Richardt SL, Styer DM, Gebhardt M, Juzwin KR, Yourek A, Aldridge D. Psychotherapeutic approaches to non-suicidal self-injury in adolescents. Child Adolesc Psychiatry Ment Health 2012; 6:14. [PMID: 22463499 PMCID: PMC3782878 DOI: 10.1186/1753-2000-6-14] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 03/30/2012] [Indexed: 11/10/2022] Open
Abstract
Non-suicidal self-injury (NSSI) among adolescents is gaining increasing attention in both clinical and scientific arenas. The lifetime prevalence of NSSI is estimated to vary between 7.5% to 8% for preadolescents, increasing to between 12% and 23% for adolescents. Despite the prevalence and the increasing interest in NSSI, few psychotherapeutic treatments have been designed specifically for NSSI, and no treatments have been evaluated specifically for the treatment of NSSI among adolescents. Consequently, child and adolescent clinicians are left with little evidence-based guidance for treating this challenging population. To provide some guidance, evaluations of treatments for adults with NSSI and for adolescents with related conditions, such as deliberate self-harm and borderline personality disorder, are reviewed. Clinical guidelines and resources are also discussed to assist with the gaps in the knowledge base for treatment of NSSI among adolescents.
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Affiliation(s)
- Jason J Washburn
- Alexian Brothers Behavioral Health Hospital, Center for Evidence-Based Practice, 1650 Moon Lake Blvd, Hoffman Estates, IL 60169, USA
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Drive, Chicago, IL 60611, USA
| | - Sarah L Richardt
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 710 N. Lake Shore Drive, Chicago, IL 60611, USA
| | - Denise M Styer
- Alexian Brothers Behavioral Health Hospital, Center for Evidence-Based Practice, 1650 Moon Lake Blvd, Hoffman Estates, IL 60169, USA
| | - Michelle Gebhardt
- Alexian Brothers Behavioral Health Hospital, Center for Evidence-Based Practice, 1650 Moon Lake Blvd, Hoffman Estates, IL 60169, USA
| | - K R Juzwin
- Alexian Brothers Behavioral Health Hospital, Center for Evidence-Based Practice, 1650 Moon Lake Blvd, Hoffman Estates, IL 60169, USA
- College of Psychology and Behavioral Sciences, Argosy University, 999 N. Plaza Drive, Schaumburg, IL, 60173, USA
| | - Adrienne Yourek
- Alexian Brothers Behavioral Health Hospital, Center for Evidence-Based Practice, 1650 Moon Lake Blvd, Hoffman Estates, IL 60169, USA
| | - Delia Aldridge
- Alexian Brothers Behavioral Health Hospital, Center for Evidence-Based Practice, 1650 Moon Lake Blvd, Hoffman Estates, IL 60169, USA
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95
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Shamseddeen W, Clarke G, Keller MB, Wagner KD, Birmaher B, Emslie GJ, Ryan N, Asarnow JR, Porta G, Brent DA. Adjunctive sleep medications and depression outcome in the treatment of serotonin-selective reuptake inhibitor resistant depression in adolescents study. J Child Adolesc Psychopharmacol 2012; 22:29-36. [PMID: 22251024 PMCID: PMC3281285 DOI: 10.1089/cap.2011.0027] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE In the Treatment of Resistant Depression in Adolescents, study participants who received medication for sleep had a lower response rate. This report sought to clarify this finding. METHOD Depressed adolescents who had not responded to a previous adequate serotonin-selective reuptake inhibitor (SSRI) trial were randomly assigned to another SSRI, venlafaxine, another SSRI+cognitive behavior therapy (CBT), or venlafaxine+CBT. Augmentation with sleep medication was permitted as clinically indicated. RESULTS Youth who received trazodone were six times less likely to respond than those with no sleep medication (adjusted odds ratio [OR]=0.16, 95% confidence interval [CI]: 0.05-0.50, p=0.001) and were three times more likely to experience self-harm (OR=3.0, 95% CI: 1.1-7.9, p=0.03), even after adjusting for baseline differences associated with trazodone use. None (0/13) of those cotreated with trazodone and either paroxetine or fluoxetine responded. In contrast, those treated with other sleep medications had similar rates of response (60.0% vs. 50.4%, χ(2)=0.85, p=0.36) and of self-harm events (OR=0.5, 95% CI: 0.1-2.6, p=0.53) as those who received no sleep medication. CONCLUSIONS These findings should be interpreted cautiously because these sleep agents were not assigned randomly, but at clinician discretion. Nevertheless, they suggest that the use of trazodone for the management of sleep difficulties in adolescent depression should be re-evaluated and that future research on the management of sleep disturbance in adolescent depression is needed. The very low response rate of participants cotreated with trazodone and either fluoxetine or paroxetine could be due to inhibition of CYP 2D6 by these antidepressants.
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Affiliation(s)
- Wael Shamseddeen
- Rosalind Franklin University of Medicine and Sciences, North Chicago, Illinios
| | - Gregory Clarke
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | | | | | - Graham J. Emslie
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
| | - Neal Ryan
- University of Pittsburgh, Pittsburgh, Pennsylvania
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96
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Wagner KD, Asarnow JR, Vitiello B, Clarke G, Keller M, Emslie GJ, Ryan N, Porta G, Iyengar S, Ritz L, Zelanzny J, Onorato M, Brent D. Out of the black box: treatment of resistant depression in adolescents and the antidepressant controversy. J Child Adolesc Psychopharmacol 2012; 22:5-10. [PMID: 22251022 PMCID: PMC3281287 DOI: 10.1089/cap.2011.0045] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this article is to describe the effects of the pediatric antidepressant controversy on the Treatment of Serotonin-Selective Reuptake Inhibitor (SSRI) Resistant Depression in Adolescents (TORDIA) trial. METHOD Adolescents, ages 12-18 years, with SSRI resistant depression were randomized to one of four treatments for a 12 week trial: Switch to different SSRI, switch to an alternate antidepressant (venlafaxine), switch to an alternate SSRI plus cognitive behavior therapy (CBT), or switch to venlafaxine plus CBT. RESULTS The health advisories and "black box" warnings regarding suicidality and antidepressants in adolescents occurred during the course of the TORDIA trial. Revisions to the protocol, multiple-consent form changes, and re-consenting of patients were necessary. Recruitment of participants was adversely affected. CONCLUSION Despite a cascade of unforeseen events that delayed the completion of the study, the TORDIA trial resulted in clinically important information about treatment-resistant depression in adolescents.
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Affiliation(s)
- Karen Dineen Wagner
- Division of Child and Adolescent Psychiatry, The University of Texas Medical Branch, Galveston, Texas 77555, USA.
| | - Joan Rosenbaum Asarnow
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, California
| | - Benedetto Vitiello
- Child and Adolescent Treatment and Preventative Intervention Research Branch, NIMH, Bethesda, Maryland
| | - Gregory Clarke
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | - Martin Keller
- Department of Psychiatry, Brown University, Providence, Rhode Island
| | - Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Neal Ryan
- Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Giovanna Porta
- Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Satish Iyengar
- Department of Statistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Louise Ritz
- Department of Research, National Institute of Mental Health, Bethesda, Maryland. Currently affiliated with National Institute of Neurological Disorders and Stroke (NINDS), Bethesda, Maryland
| | - Jamie Zelanzny
- Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew Onorato
- Department of Psychiatry, Nationwide Children's Hospital, Columbus, Ohio.,Department of Psychiatry, The Ohio State University, Columbus, Ohio
| | - David Brent
- Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania
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97
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Emslie GJ, Kennard BD, Mayes TL, Nakonezny PA, Zhu L, Tao R, Hughes C, Croarkin P. Insomnia moderates outcome of serotonin-selective reuptake inhibitor treatment in depressed youth. J Child Adolesc Psychopharmacol 2012; 22:21-8. [PMID: 22257126 PMCID: PMC3281293 DOI: 10.1089/cap.2011.0096] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Insomnia is evident in the majority of youth with depression, and is associated with poorer outcomes. There are limited data on the impact of insomnia in response to acute treatment, which is particularly relevant with serotonin-selective reuptake inhibitors, given their tendency to worsen sleep architecture. METHODS Three hundred nine children and adolescents (ages 7-18 years) were randomized to fluoxetine (n=157) or placebo (n=152) for 8-9 weeks (Emslie et al.1997, 2002). Substantial insomnia at baseline was defined as a child's depression rating scale-revised [CDRS-R] sleep item ≥ 4. Outcome measures were CDRS-R, response, and remission. RESULTS Insomnia was reported in 172/309 (55.7%) youth, and was associated with higher depression severity and greater fatigue, suicidal ideation, physical complaints, and decreased concentration. While response rates were similar in those with or without insomnia overall (51.7% vs. 55.7%), there is a significant difference by age group. Among adolescents, those with insomnia were less likely to respond to fluoxetine (39.2%; 20/51) than those without (65.9%; 27/41; p=0.013), while in children on fluoxetine, those with insomnia were more likely to respond to fluoxetine (69.4%; 25/36) than those without insomnia (41.4%; 12/29; p=0.027). Insomnia did not impact the response to placebo in either age group. Within adolescents, the overall least squares means for CDRS-R total score (across the 8 weeks of treatment) were significantly different between those who had insomnia versus those who did not within the fluoxetine group (43.65 [SE=1.31] vs. 36.58[SE=1.45], F=12.69, df=1, 169, p=0.0005; d=0.82), but not within the placebo group (44.91[SE=1.34] vs. 43.75[SE=1.68], F=0.29, df=1, 179, p=0.591; d=0.15). CONCLUSIONS While adolescents reporting substantial insomnia were less likely to respond to antidepressant treatment than those without insomnia, children were more responsive to fluoxetine when they had insomnia. Additional intervention targeting sleep disturbance may be warranted in adolescents.
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Affiliation(s)
- Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Betsy D. Kennard
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Taryn L. Mayes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Paul A. Nakonezny
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lian Zhu
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rongrong Tao
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Carroll Hughes
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Paul Croarkin
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
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98
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Affiliation(s)
- Graham J. Emslie
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
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99
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Forbes EE, Stepp SD, Dahl RE, Ryan ND, Whalen D, Axelson DA, Birmaher B, Silk JS. Real-world affect and social context as predictors of treatment response in child and adolescent depression and anxiety: an ecological momentary assessment study. J Child Adolesc Psychopharmacol 2012; 22:37-47. [PMID: 22339611 PMCID: PMC3281286 DOI: 10.1089/cap.2011.0085] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Response to treatment in child and adolescent affective disorders is variable, with limited ability of any one treatment to improve outcome across patients. Unfortunately, we know little about the factors that explain this variability in treatment response. Individual differences in the social and affective dynamics of daily life could help to elucidate the characteristics of youth who respond to treatment. METHODS We used ecological momentary assessment of negative affect, positive affect, and companions in natural settings over 4 days in a sample of young people with depressive and anxiety disorders who participated in an 8-week open trial of cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), or a combination of the two. Clinicians rated participants' clinical severity at five time points, and participants reported their symptoms before and after treatment. Latent growth curve models were used to predict rate of change in clinical severity from pretreatment affect in natural settings. RESULTS Participants with high positive affect (PA), low negative affect (NA), and a high PA:NA ratio at baseline had lower severity, depressive symptoms, and anxiety symptoms at the end of treatment. Lower posttreatment symptoms were associated with spending more time with fathers and less time with peers before treatment. Although baseline affect was not associated with initial symptom severity, high NA and low PA:NA at baseline were related to slower rate of decline of severity during treatment. When baseline symptoms were included in models, NA and PA:NA predicted rate of decline in severity during treatment, whereas self-reported depressive and anxiety symptoms at baseline did not. CONCLUSION A more typical profile of baseline affective functioning in natural settings-that is, lower NA and higher PA-and time with fathers, could provide a foundation for treatment response in children and adolescents. Affective and social dynamics in natural settings could ultimately help investigate which young people might benefit from current treatments.
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Affiliation(s)
| | | | | | - Neal D. Ryan
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Diana Whalen
- University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
PURPOSE OF REVIEW Adolescent depression is a chronic, pervasive, and disabling problem that is often under-recognized and under-treated. The objective of this article is to review recent (over the past 12-18 months) literature on the management of depression in adolescents, with a particular focus on pharmacological and psychological treatments as well as community and internet-based prevention and treatment programmes. RECENT FINDINGS The tendency for depression in young people to be associated with a number of other disorders and behaviours, including anxiety, suicide, conduct disorder and substance abuse, compounds the complexity of management and can contribute to a negative long-term impact on adult mental health. Results of recent randomized controlled trials have reinforced our understanding that the management of moderate-to-severe depression in adolescents should be assertive and prompt, typically including a combination of psychological and pharmacological interventions. SUMMARY While the development of novel treatments is evolving, there is an urgent need to focus on defining the optimal use of available therapies and tailoring these to individual presentations, as well as upon improving identification of adolescent depressive disorders in the community.
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