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Akaltun İ, Ayaydin H. Fluoxetine-related mania in an adolescent girl diagnosed with selective mutism: A case report. Asia Pac Psychiatry 2020; 12:e12367. [PMID: 31222962 DOI: 10.1111/appy.12367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/30/2019] [Indexed: 12/01/2022]
Affiliation(s)
- İsmail Akaltun
- Department of Child and Adolescent Psychiatry, Gaziantep Dr. Ersin Arslan Training and Research Hospital, Gaziantep, Turkey
| | - Hamza Ayaydin
- Department of Child and Adolescent Psychiatry, Faculty of Medicine, Harran University, Şanlıurfa, Turkey
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Towbin K, Vidal-Ribas P, Brotman MA, Pickles A, Miller KV, Kaiser A, Vitale AD, Engel C, Overman GP, Davis M, Lee B, McNeil C, Wheeler W, Yokum CH, Haring CT, Roule A, Wambach CG, Sharif-Askary B, Pine DS, Leibenluft E, Stringaris A. A Double-Blind Randomized Placebo-Controlled Trial of Citalopram Adjunctive to Stimulant Medication in Youth With Chronic Severe Irritability. J Am Acad Child Adolesc Psychiatry 2020; 59:350-361. [PMID: 31128268 PMCID: PMC9706653 DOI: 10.1016/j.jaac.2019.05.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 03/08/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Despite the clinical importance of chronic and severe irritability, there is a paucity of controlled trials for its pharmacological treatment. Here, we examine the effects of adding citalopram (CTP) to methylphenidate (MPH) in the treatment of chronic severe irritability in youth using a double-blind randomized placebo-controlled design. METHOD After a lead-in phase of open treatment with stimulant, 53 youth meeting criteria for severe mood dysregulation (SMD) were randomly assigned to receive CTP or placebo (PBO) for 8 weeks. A total of 49 participants, 48 of them (98%) meeting disruptive mood dysregulation disorder (DMDD) criteria, were included in the intent-to-treat analysis. The primary outcome measure was the proportion of response based on improvements of irritability at the week 8 of the trial. RESULTS At the end of the trial, a significantly higher proportion of response was seen in those participants randomly assigned to CTP+MPH compared to PBO+MPH (35% CTP+MPH versus 6% PBO+MPH; odds ratio = 11.70, 95% CI = 2.00-68.16, p = 0.006). However, there were no differences in functional impairment between groups at the end of the trial. No differences were found in any adverse effect between treatment groups, and no trial participant exhibited hypomanic or manic symptoms. CONCLUSION Adjunctive CTP might be efficacious in the treatment of chronic severe irritability in youth resistant to stimulant treatment alone. CLINICAL TRIAL REGISTRATION INFORMATION A Controlled Trial of Serotonin Reuptake Inhibitors Added to Stimulant Medication in Youth With Severe Mood Dysregulation; https://clinicaltrials.gov; NCT00794040.
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Affiliation(s)
- Kenneth Towbin
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Pablo Vidal-Ribas
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD.,Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK
| | - Melissa A. Brotman
- Neuroscience and Novel Therapeutics, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Andrew Pickles
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK
| | - Katherine V. Miller
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Ariela Kaiser
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Aria D. Vitale
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Chana Engel
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | | | - Mollie Davis
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Beth Lee
- College of Nursing, University of Arizona, Tuscon
| | - Cheri McNeil
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Wanda Wheeler
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Catherine H. Yokum
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | | | | | | | | | - Daniel S. Pine
- Section on Development and Affective Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Argyris Stringaris
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD.
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Dwyer JB, Stringaris A, Brent DA, Bloch MH. Annual Research Review: Defining and treating pediatric treatment-resistant depression. J Child Psychol Psychiatry 2020; 61:312-332. [PMID: 32020643 PMCID: PMC8314167 DOI: 10.1111/jcpp.13202] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/31/2019] [Accepted: 01/03/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Adolescent major depressive disorder (MDD) is a significant health problem, associated with substantial morbidity, cost, and mortality. Depression is a significant risk factor for suicide, which is now the second leading cause of death in young people. Up to twenty per cent of adolescents will experience MDD before adulthood, and while a substantial proportion will improve with standard-of-care treatments (psychotherapy and medication), roughly one third will not. METHODS Here, we have reviewed the literature in order to discuss the concept of treatment-resistant depression (TRD) in adolescence, examine risk factors, diagnostic difficulties, and challenges in evaluating symptom improvement, and providing guidance on how to define adequate medication and psychotherapy treatment trials. RESULTS We propose a staging model for adolescent TRD and review the treatment literature. The evidence base for first- and second-line treatments primarily derives from four large pediatric clinical trials (TADS, TORDIA, ADAPT, and IMPACT). After two medications and a trial of evidence-based psychotherapy have failed to alleviate depressive symptoms, the evidence becomes quite thin for subsequent treatments. Here, we review the evidence for the effectiveness of medication switches, medication augmentation, psychotherapy augmentation, and interventional treatments (i.e., transcranial magnetic stimulation, electroconvulsive therapy, and ketamine) for adolescent TRD. Comparisons are drawn to the adult TRD literature, and areas for future pediatric depression research are highlighted. CONCLUSIONS As evidence is limited for treatments in this population, a careful consideration of the known risks and side effects of escalated treatments (e.g., mood stabilizers and atypical antipsychotics) is warranted and weighed against potential, but often untested, benefits.
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Affiliation(s)
- Jennifer B. Dwyer
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA,Yale Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Argyris Stringaris
- Mood Brain and Development Unit, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - David A. Brent
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,University of Pittsburgh Medical Center Western Psychiatric Hospital, Pittsburgh, PA, USA
| | - Michael H. Bloch
- Yale Child Study Center, Yale University School of Medicine, New Haven, CT, USA,Yale Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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The Effect of Cognitive Behavioral Therapy on Anxiety and Depression in Iranian Infertile Women: A Systematic and Meta-Analytical Review. IRANIAN JOURNAL OF PSYCHIATRY AND BEHAVIORAL SCIENCES 2020. [DOI: 10.5812/ijpbs.96715] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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105
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Townsend L, Kobak K, Kearney C, Milham M, Andreotti C, Escalera J, Alexander L, Gill MK, Birmaher B, Sylvester R, Rice D, Deep A, Kaufman J. Development of Three Web-Based Computerized Versions of the Kiddie Schedule for Affective Disorders and Schizophrenia Child Psychiatric Diagnostic Interview: Preliminary Validity Data. J Am Acad Child Adolesc Psychiatry 2020; 59:309-325. [PMID: 31108163 DOI: 10.1016/j.jaac.2019.05.009] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 04/29/2019] [Accepted: 05/13/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To present initial validity data on three web-based computerized versions of the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-COMP). METHOD The sample for evaluating the validity of the clinician-administered KSADS-COMP included 511 youths 6-18 years of age who were participants in the Child Mind Institute Healthy Brain Network. The sample for evaluating the parent and youth self-administered versions of the KSADS-COMP included 158 youths 11-17 years of age recruited from three academic institutions. RESULTS Average administration time for completing the combined parent and youth clinician-administered KSADS-COMP was less time than previously reported for completing the paper-and-pencil K-SADS with only one informant (91.9 ± 50.1 minutes). Average administration times for the youth and parent self-administered KSADS-COMP were 50.9 ± 28.0 minutes and 63.2 ± 38.3 minutes, respectively, and youths and parents rated their experience using the web-based self-administered KSADS-COMP versions very positively. Diagnoses generated with all three KSADS-COMP versions demonstrated good convergent validity against established clinical rating scales and dimensional diagnostic-specific ratings derived from the KSADS-COMP. When parent and youth self-administered KSADS-COMP data were integrated, good to excellent concordance was also achieved between diagnoses derived using the self-administered and clinician-administered KSADS-COMP versions (area under the curve = 0.89-1.00). CONCLUSION The three versions of the KSADS-COMP demonstrate promising psychometric properties, while offering efficiency in administration and scoring. The clinician-administered KSADS-COMP shows utility not only for research, but also for implementation in clinical practice, with self-report preinterview ratings that streamline administration. The self-administered KSADS-COMP versions have numerous potential research and clinical applications, including in large-scale epidemiological studies, in schools, in emergency departments, and in telehealth to address the critical shortage of child and adolescent mental health specialists. CLINICAL TRIAL REGISTRATION INFORMATION Computerized Screening for Comorbidity in Adolescents With Substance or Psychiatric Disorders; https://clinicaltrials.gov/; NCT01866956.
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Affiliation(s)
- Lisa Townsend
- Kennedy Krieger Institute, Baltimore, MD; Johns Hopkins School of Medicine, Baltimore, MD
| | | | | | - Michael Milham
- Child Mind Institute, New York, NY; Nathan Kline Institute, Orangeburg, NY
| | | | | | | | - Mary Kay Gill
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, PA
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, PA
| | - Raeanne Sylvester
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, PA
| | - Dawn Rice
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, PA
| | | | - Joan Kaufman
- Kennedy Krieger Institute, Baltimore, MD; Johns Hopkins School of Medicine, Baltimore, MD.
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Abstract
Pharmacogenetics is a key component of precision medicine. Genetic variation in drug metabolism enzymes can lead to variable exposure to drugs and metabolites, potentially leading to inefficacy and drug toxicity. Although the evidence for pharmacogenetic associations in children is not as extensive as for adults, there are several drugs across diverse therapeutic areas with robust pediatric data indicating important, and relatively common, drug-gene interactions. Guidelines to assist gene-based dose optimization are available for codeine, thiopurine drugs, selective serotonin reuptake inhibitors, atomoxetine, tacrolimus, and voriconazole. For each of these drugs, there is an opportunity to clinically implement precision medicine approaches with children for whom genetic test results are known or are obtained at the time of prescribing. For many more drugs that are commonly used in pediatric patients, additional investigation is needed to determine the genetic factors influencing appropriate dose.
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Affiliation(s)
- Laura B Ramsey
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267, USA
- Divisions of Research in Patient Services and Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA
| | - Jacob T Brown
- Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota College of Pharmacy, Duluth, Minnesota 55812, USA
| | - Susan I Vear
- Department of Hematology & Oncology, Nationwide Children's Hospital, Columbus, Ohio 43205, USA
| | - Jeffrey R Bishop
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, and Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota 55455, USA
| | - Sara L Van Driest
- Departments of Pediatrics and Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA;
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Associations between cognitive errors and mental health status in New Zealand adolescents. Behav Cogn Psychother 2019; 48:280-290. [PMID: 31718722 DOI: 10.1017/s1352465819000626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cognitive models of psychopathology suggest that negatively biased thinking styles are involved in the development and maintenance of emotional disturbances. AIMS The present study examined the relationships between negative cognitive errors and indices of mental health status (i.e. anxiety and depression) in New Zealand adolescents. METHOD A community sample of 490 youth aged 16-18 years completed an anonymous online survey consisting of the Children's Negative Cognitive Error Questionnaire (CNCEQ), the Trait subscale of the State-Trait Anxiety Inventory (STAI-T) and the Center for Epidemiologic Studies Depression Scale (CES-D). RESULTS Negative cognitive errors correlated positively with greater levels of anxious and depressive symptoms. Hierarchical regression analyses indicated that overall cognitive error score was a strong predictor of adolescents' self-reported anxious symptoms and, to a lesser extent, depressive symptoms. Moreover, cognitive errors significantly differentiated between adolescents with high scores from adolescents with low scores on both the anxiety (STAI-T) and the depression (CES-D) scales. CONCLUSIONS These findings lend support to the generalizability of Beck's cognitive theory to a New Zealand adolescent population and highlight the importance of focusing on prevention and early intervention programmes that directly target these faulty or biased ways of thinking in adolescents with anxious and/or depressive symptoms before meeting diagnostic criteria.
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108
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Brent DA, Porta G. Error in Coding of Questionnaire Scale in Study of Depression in Adolescents. JAMA 2019; 322:1717-1718. [PMID: 31609395 DOI: 10.1001/jama.2019.12855] [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: 11/14/2022]
Affiliation(s)
- David A Brent
- Western Psychiatric Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Giovanna Porta
- Western Psychiatric Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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109
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Error in Coding of Suicidal Ideation Questionnaire Scale. JAMA 2019; 322:1718. [PMID: 31609396 PMCID: PMC6802242 DOI: 10.1001/jama.2019.16240] [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: 11/14/2022]
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110
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Dhami P, Knyahnytska Y, Atluri S, Lee J, Courtney DB, Croarkin PE, Blumberger DM, Daskalakis ZJ, Farzan F. Feasibility and clinical effects of theta burst stimulation in youth with major depressive disorders: An open-label trial. J Affect Disord 2019; 258:66-73. [PMID: 31398593 DOI: 10.1016/j.jad.2019.07.084] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Conventional treatments for youth depression, such as antidepressants, have modest efficacy, side effects, and ongoing controversies regarding safety. Repetitive transcranial magnetic stimulation (rTMS), specifically theta burst stimulation (TBS), applied to the dorsolateral prefrontal cortex (DLPFC) has demonstrated efficacy for the treatment of depression in adults. However, the feasibility and clinical response to TBS for youth depression has yet to be explored. METHODS Twenty participants between the ages of 16 to 24 years old with MDD were recruited. The intervention consisted of 10 treatment sessions over the course of two weeks, in which participants received intermittent TBS and continuous TBS stimulation to the left and right DLPFC, respectively. Change in the Hamilton Rating Scale for Depression (HRSD-17) score was the primary outcome. Clinical assessments occurred at baseline, after the fifth treatment session, and within a week after treatment completion. RESULTS Of the twenty participants, eighteen received all TBS sessions, and seventeen completed all clinical assessments. There was a significant reduction in depressive symptoms following treatment completion (p < 0.001). Four of the twenty patients had more than 50% reduction in their depressive symptoms, two of whom achieved remission. All participants received and tolerated at least six daily TBS treatments with no major adverse events. LIMITATIONS Study was an uncontrolled, open-label design. CONCLUSION Ten sessions of TBS was feasible, well tolerated, and appeared to have clinical effects for the treatment of depressed youth. Future sham-controlled randomized trials are warranted to validate these findings in a larger cohort of youth depression.
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Affiliation(s)
- Prabhjot Dhami
- Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, Ontario, M6J 1A8, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Yuliya Knyahnytska
- Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, Ontario, M6J 1A8, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, M5T 1R8, Canada
| | - Sravya Atluri
- Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, Ontario, M6J 1A8, Canada; Institute of Biomaterial and Biomedical Engineering, Rosebrugh Building, Room 407, 164 College St, Toronto, Ontario, M5S 3G9, Canada
| | - Jonathan Lee
- Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, Ontario, M6J 1A8, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, M5T 1R8, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Darren B Courtney
- Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, Ontario, M6J 1A8, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, M5T 1R8, Canada
| | | | - Daniel M Blumberger
- Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, Ontario, M6J 1A8, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, M5T 1R8, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Zafiris J Daskalakis
- Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, Ontario, M6J 1A8, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, M5T 1R8, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Faranak Farzan
- Centre for Addiction and Mental Health, 1001 Queen St. W, Toronto, Ontario, M6J 1A8, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, M5T 1R8, Canada; Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, Ontario, M5S 1A8, Canada; School of Mechatronic Systems Engineering, Simon Fraser University, 250-13450 102 Avenue, Surrey, British Columbia, V3T 0A3, Canada.
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Courtney DB, Cheung A, Henderson J, Bennett K, Battaglia M, Strauss J, Mitchell R, Wang K, Szatmari P. Effectiveness of an Integrated Care Pathway for Adolescents with Depression: A Pilot Clinical Trial Protocol. JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY = JOURNAL DE L'ACADEMIE CANADIENNE DE PSYCHIATRIE DE L'ENFANT ET DE L'ADOLESCENT 2019; 28:115-133. [PMID: 31798650 PMCID: PMC6863574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 09/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Our group aims to improve treatment response for adolescents with depression through the use of an Integrated Care Pathway (ICP) we developed using: (1) recommendations from a high quality Clinical Practice Guideline (CPG); and, (2) a measurement-based care framework. METHOD Pre-specified criteria will identify eligible adolescents in two outpatient hospital study sites. Study group allocation, to the ICP versus treatment as usual (TAU), is based on site of presentation. The primary clinical outcome is reduction of depression symptoms, assessed using the Childhood Depression Rating Scale - Revised (CDRS-R). Measures will be taken at baseline and every four weeks until 20 weeks of treatment has been offered. RESULTS Our overall hypothesis is that the ICP will be associated with greater improvement in depressive symptoms compared to TAU. Feasibility targets for this pilot trial include the following: recruitment of 30 participants per site over a 21-month period, 95% baseline assessment completion rates, 90% clinician adherence to the ICP in the intervention arm and 80% completion of the scheduled CDRS-R measures over the 20-week interval. Focus-group feedback from youth and parents will also produce qualitative information. CONCLUSIONS If feasibility targets are met, and preliminary results regarding clinical outcomes are promising, then a multi-center cluster RCT would be pursued.
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Affiliation(s)
- Darren B Courtney
- Centre for Addiction and Mental Health (CAMH), Assistant Professor, University of Toronto, Toronto, Ontario
| | - Amy Cheung
- Sunnybrook Health Sciences Centre, Associate Professor, University of Toronto, Toronto, Ontario
| | - Joanna Henderson
- Centre for Addiction and Mental Health (CAMH), Associate Professor, University of Toronto, Toronto Ontario
| | - Kathryn Bennett
- Professor, Health Research Methods, Evidence and Impact (formerly Clinical Epidemiology and Biostatistics), McMaster University, Hamilton, Ontario
| | - Marco Battaglia
- Centre for Addiction and Mental Health (CAMH), Associate Professor, University of Toronto, Toronto, Ontario
| | - John Strauss
- Centre for Addiction and Mental Health (CAMH), Associate Professor, University of Toronto, Toronto, Ontario
| | - Rachel Mitchell
- Sunnybrook Health Sciences Centre, Assistant Professor, University of Toronto, Toronto, Ontario
| | - Karen Wang
- Sunnybrook Health Sciences Centre, Assistant Professor, University of Toronto, Toronto, Ontario
| | - Peter Szatmari
- Centre for Addiction and Mental Health (CAMH), Hospital for Sick Children, Professor, University of Toronto, Toronto, Ontario
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Biagiarelli M, Curto M, Listanti G, Andraos MP, Pazzelli F, Aprile V, Pelaccia S, Mantovani B, Caccia F, Carpentieri R, Trabucchi G, Tambelli R, Girardi P, Ferracuti S, Baldessarini RJ, Sarlatto C. Efficacy of the Cooperative Assessment Method (COOPAS) to Improve the Psychiatric Care of Help-Seeking Adolescents. CLINICAL NEUROPSYCHIATRY 2019; 16:189-196. [PMID: 34908955 PMCID: PMC8650201 DOI: 10.36131/clinicalnpsych2019050601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective Effective treatment of adolescents with psychopathological disorders is essential to reduce later morbidity and disability. To evaluate the clinical value of a new adolescent Cooperative Assessment scheme (COOPAS) as indicated by establishing therapeutic alliance, improving symptoms, and particularly by reducing dropouts. Method Consecutive help-seeking adolescents (N=136) were recruited, evaluated with an 8-week COOPAS protocol and followed for 6 months to document dropouts during treatment. Clinical rating scales [Hamilton Depression and Anxiety scales (HAM-D, HAM-A), Global Functioning Role and Social Scales (GF-RS, GF-SS), Structured Interview for Prodromal Symptoms (SIPS), Clinical Global Impression (CGI), Working Alliance Inventory-Therapist version (WAI-T), Therapist Response Questionnaire (TRQ), Psychotherapy Relationship Questionnaire (PRQ)] were administered at intake, 4 weeks later, and at the end of COOPAS evaluation (8 weeks). Results Final HAM-A and HAM-D scores improved by 25%; CGI, GF-SS and GF-RS also improved significantly. Similarly, WAI-T showed significant improvements in all three subscales, and patient-clinician relationships (PRQ) showed decreases in Anxious/Preoccupied and Avoidant/Counterdependent dimensions with increases of the Secure/Engaged measure. After 6 months, dropout rate was 8.82%. Conclusions COOPAS assessment was followed by reduced depressive and anxiety symptoms, good therapeutic alliance, and low dropout in adolescents.
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Affiliation(s)
- Mario Biagiarelli
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy.,Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Martina Curto
- Department of Human Neurosciences, Sapienza University of Rome, Italy.,International Consortium for Mood and Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, Massachusetts, USA
| | - Giulia Listanti
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Maria Paola Andraos
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Floriana Pazzelli
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Veronica Aprile
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Simona Pelaccia
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Beatrice Mantovani
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Federica Caccia
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Renato Carpentieri
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Guido Trabucchi
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Renata Tambelli
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Paolo Girardi
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
| | - Stefano Ferracuti
- Department of Human Neurosciences, Sapienza University of Rome, Italy
| | - Ross J Baldessarini
- International Consortium for Mood and Psychotic Disorders Research, Mailman Research Center, McLean Hospital, Belmont, Massachusetts, USA.,Department of Psychiatry, McLean Hospital, Harvard Medical School
| | - Cinzia Sarlatto
- NESMOS Department (Neurosciences, Mental Health and Sensory Organs), Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Italy
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The addition of fluoxetine to cognitive behavioural therapy for youth depression (YoDA-C): a randomised, double-blind, placebo-controlled, multicentre clinical trial. Lancet Psychiatry 2019; 6:735-744. [PMID: 31371212 DOI: 10.1016/s2215-0366(19)30215-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Medication is commonly used to treat youth depression, but whether medication should be added to cognitive behavioural therapy (CBT) as first-line treatment is unclear. We aimed to examine whether combined treatment with CBT and fluoxetine was more effective than CBT and placebo in youth with moderate-to-severe major depressive disorder. METHODS The Youth Depression Alleviation-Combined Treatment (YoDA-C) trial was a randomised, double-blind, placebo-controlled, multicentre clinical trial. Participants were aged 15-25 years with moderate-to-severe MDD and had sought care at one of four clinical centres in metropolitan Melbourne, Australia. Patients were randomly assigned (1:1) to receive CBT for 12 weeks, plus either fluoxetine or placebo. Participants began on one 20 mg capsule of fluoxetine or one placebo pill per day. All participants received CBT, delivered by therapists in weekly 50-minute sessions and attended interviews at baseline, and at weeks 4, 8, and 12, during which they completed assessments with research assistants. Participants saw a psychiatrist or psychiatry trainee to complete medical assessments at the same timepoints. The primary outcome was change in the interviewer-rated Montgomery-Åsberg Depression Rating Scale (MADRS) score at 12 weeks. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612001281886). FINDINGS 153 participants (mean age 19·6 years [SD 2·7]) were enrolled from Feb 20, 2013, to Dec 13, 2016. 77 (50%) patients were allocated to CBT and placebo and 76 (50%) to CBT and fluoxetine. Participants had severe depression at baseline (mean MADRS score 33·6 [SD 5·1] in the CBT and placebo group and 32·2 [5·6] in the CBT and fluoxetine group), with high proportions of participants with anxiety disorder comorbidity (47 [61%] in the CBT and placebo group and 49 [64%] in the CBT and fluoxetine group) and past-month suicidal ideation (55 [71%] in the CBT and placebo group and 59 [78%] in the CBT and fluoxetine group). 59 (77%) participants in the CBT and placebo group and 64 (84%) in the CBT and fluoxetine group completed follow-up at week 12. After 12 weeks of treatment both groups showed a reduction in MADRS scores (-13·7, 95% CI -16·0 to -11·4, in the CBT and placebo group and -15·1, -17·4 to -12·9, in the CBT and fluoxetine group). There was no significant between-group difference in MADRS scores (-1·4, -4·7 to 1·8; p=0·39). There were five suicide attempts in the CBT and placebo group and one suicide attempt in the CBT and fluoxetine group (odds ratio 0·2, 0·0-1·8; p=0·21), and no significant between-group differences for other suicidal behaviours. INTERPRETATION We did not find evidence that the addition of fluoxetine (rather than placebo) to CBT further reduced depressive symptoms in young people with moderate-to-severe MDD. Exploratory analyses showed that the addition of medication might be helpful for patients with comorbid anxiety symptoms and for older youth. FUNDING Australian National Health and Medical Research Council.
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Vitiello B. Youth depression: are two treatments better than one? Lancet Psychiatry 2019; 6:714-715. [PMID: 31371211 DOI: 10.1016/s2215-0366(19)30281-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 07/08/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Benedetto Vitiello
- Department of Public Health and Pediatric Sciences, Section of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy.
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Dardas LA. Family functioning moderates the impact of depression treatment on adolescents' suicidal ideations. Child Adolesc Ment Health 2019; 24:251-258. [PMID: 32677215 DOI: 10.1111/camh.12323] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2019] [Indexed: 01/22/2023]
Abstract
PURPOSE The purpose of this study was to explore whether adolescent-perceived family functioning moderates the depression treatment effects on suicidal ideations. METHODS This is a nonpreregistered exploratory secondary analysis of the TADS RCT, which included four treatment groups: fluoxetine, CBT, their combination, and placebo. A random coefficients regression model with posteriori CONTRAST statements was conducted to examine the effects of depression treatment on adolescents' suicidal ideations over time (N = 439). Baron and Kenny's (1986) and Kraemer et al.'s (2002) approach was followed to explore family functioning as a potential moderator of the treatment effects on suicidal ideations over time. RESULTS Adolescents in the four treatment groups did not differ significantly in their suicidal ideations at initial status; however, those in the combination group had faster reduction in suicidality. Family functioning moderated the relationship between depression treatment and adolescents' suicidal ideations. In particular, the results revealed that for adolescents who reported positive family functioning (n = 249), treatment had a significant impact on their suicidal ideations over time. However, for adolescents who reported negative family functioning (n = 190), type of treatment did not have a differential effect on improvement in severity of suicidal ideation over time. CONCLUSION Findings provided evidence that the process by which depression treatment impacts adolescents' suicidality is contingent upon their family environment. Family-centered approaches to adolescent depression treatment are recommended.
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Abbott CH, Zisk A, Bounoua N, Diamond GS, Kobak R. Predicting Patterns of Treatment Response and Outcome for Adolescents Who Are Suicidal and Depressed. J Am Acad Child Adolesc Psychiatry 2019; 58:897-906. [PMID: 30877051 DOI: 10.1016/j.jaac.2018.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 12/12/2018] [Accepted: 01/23/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although several treatments have been shown to be effective in treatment of youth suicidal thoughts and behaviors (STBs), there is a pressing need to account for the substantial variation in adolescents' response to and outcomes from these treatments. METHOD Secondary analyses of data from a 16-week randomized trial of Attachment-Based Family Therapy (ABFT) and Family-Enhanced NonDirective Supportive Therapy (FE-NST) identified distinct classes of adolescents' treatment response. Established risk factors for STBs, along with treatment condition and sociodemographic variables, were then tested as predictors of class membership. RESULTS Three patterns of adolescents' treatment response and outcome were identified: a) nonresponders (15.8%), b) good responders (57.5%), and c) partial responders (26.7%). After controlling for initial symptom severity, nonresponders were more likely to have higher levels of nonsuicidal self-injury and pessimism and were more likely to meet diagnostic criteria for major depressive disorder (MDD) than good or partial responders. Partial responders were more likely than good responders to meet criteria for MDD and to have higher perceived burdensomeness. CONCLUSION Although most adolescents showed significant symptom reductions with both treatments, adolescents with higher pretreatment levels of pessimism, MDD, nonsuicidal self-injury, and perceived burdensomeness were less likely to show an optimal pattern of treatment benefit. The findings point to heterogeneity in treatment response that may require adapting treatments for adolescents with these pretreatment profiles. CLINICAL TRIAL REGISTRATION INFORMATION Attachment-Based Family Therapy for Suicidal Adolescents; http://clinicaltrials.gov; NCT01537419.
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Dwyer JB, Bloch MH. Antidepressants for Pediatric Patients. CURRENT PSYCHIATRY 2019; 18:26-42F. [PMID: 31511767 PMCID: PMC6738970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Jennifer B Dwyer
- Child Study Center, Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
| | - Michael H Bloch
- Child Study Center, Department of Psychiatry, Yale University, New Haven, Connecticut
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Tymofiyeva O, Yuan JP, Huang CY, Connolly CG, Henje Blom E, Xu D, Yang TT. Application of machine learning to structural connectome to predict symptom reduction in depressed adolescents with cognitive behavioral therapy (CBT). NEUROIMAGE-CLINICAL 2019; 23:101914. [PMID: 31491813 PMCID: PMC6627980 DOI: 10.1016/j.nicl.2019.101914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 06/14/2019] [Accepted: 06/29/2019] [Indexed: 12/29/2022]
Abstract
Purpose Adolescent major depressive disorder (MDD) is a highly prevalent, incapacitating and costly illness. Many depressed teens do not improve with cognitive behavioral therapy (CBT), a first-line treatment for adolescent MDD, and face devastating consequences of increased risk of suicide and many negative health outcomes. “Who will improve with CBT?” is a crucial question that remains unanswered, and treatment planning for adolescent depression remains biologically unguided. The purpose of this study was to utilize machine learning applied to patients' brain imaging data in order to help predict depressive symptom reduction with CBT. Methods We applied supervised machine learning to diffusion MRI-based structural connectome data in order to predict symptom reduction in 30 depressed adolescents after three months of CBT. A set of 21 attributes was chosen, including the baseline depression score, age, gender, two global network properties, and node strengths of brain regions previously implicated in depression. The practical and robust J48 pruned tree classifier was utilized with a 10-fold cross-validation. Results The classification resulted in an 83% accuracy of predicting depressive symptom reduction. The resulting tree of size seven with only three attributes highlights the role of the right thalamus in predicting depressive symptom reduction with CBT. Additional analysis showed a significant negative correlation between the change in the depressive symptoms and the node strength of the right thalamus. Conclusions Our results demonstrate that a machine learning algorithm that exclusively uses structural connectome data and the baseline depression score can predict with a high accuracy depressive symptom reduction in adolescent MDD with CBT. This knowledge can help improve treatment planning for adolescent depression. Machine learning predicted symptom reduction in depressed teens with 83% accuracy. Resulting prunned classification tree size was 7, with only 3 attributes. Change in depression symptoms correlated with node strength of the right thalamus.
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Affiliation(s)
- Olga Tymofiyeva
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, 1700 4th Street, BH102, San Francisco, CA 94143, USA.
| | - Justin P Yuan
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, 1700 4th Street, BH102, San Francisco, CA 94143, USA
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, 550 16th Street, San Francisco, CA 94143, USA
| | - Colm G Connolly
- Department of Psychiatry and the Langley Porter Psychiatric Institute, Division of Child and Adolescent Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA; Department of Biomedical Sciences, Florida State University College of Medicine, 1115 West Call Street, Tallahassee, FL 32306, USA
| | - Eva Henje Blom
- Department of Psychiatry and the Langley Porter Psychiatric Institute, Division of Child and Adolescent Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA; Department of Clinical Science/Child- and Adolescent Psychiatry, Umeå University, SE-901 87 Umeå, Sweden
| | - Duan Xu
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, 1700 4th Street, BH102, San Francisco, CA 94143, USA
| | - Tony T Yang
- Department of Psychiatry and the Langley Porter Psychiatric Institute, Division of Child and Adolescent Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA
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De Bellis MD, Nooner KB, Scheid JM, Cohen JA. Depression in Maltreated Children and Adolescents. Child Adolesc Psychiatr Clin N Am 2019; 28:289-302. [PMID: 31076108 DOI: 10.1016/j.chc.2019.02.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Maltreatment affects 9.1 to 17.1 of every 1000 US children and adolescents. Maltreated youth are at high risk for depression. Clinicians should screen young patients for maltreatment history. Depressed maltreated youth are at high risk for treatment resistance. Combination treatment with selective serotonin reuptake inhibitors and cognitive behavior therapy (CBT) with a trauma-informed approach should be considered for depressed maltreated youth. Behavioral management can be integrated with trauma-focused CBT to treat the externalizing disorders that commonly occur in maltreated depressed youth. If one approach is unsuccessful, a change to another medication or type of evidence-based psychotherapy or intervention is indicated.
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Affiliation(s)
- Michael D De Bellis
- Healthy Childhood Brain Development and Developmental Traumatology Research Program, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 104360, Durham, NC 27710, USA.
| | - Kate B Nooner
- Department of Psychology, University of North Carolina Wilmington, 601 South College Road, TL 2074, Wilmington, NC 28409, USA
| | - Jeanette M Scheid
- Department of Psychiatry, Michigan State University, 909 Wilson Road, East Lansing, MI 48824, USA
| | - Judith A Cohen
- Drexel University College of Medicine, Allegheny Health Network, 4 Allegheny Center, 8th Floor, Pittsburgh, PA 15212, USA
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Abstract
Pediatric depression is difficult to identify and manage because of complex nature of the disorder. Psychological and cognitive developments impact the clinical presentation and often make assessment tenuous. In addition, the disorder is often associated with multiple biological, psychological, and environmental risk factors, which need thorough assessment. Clinical presentation varies from subsyndromal depression to depression with psychotic features. Although diagnostic criteria for depression remain the same for children; deciphering symptoms need specialized clinical training. This article discusses identification and assessment of depression in the pediatric population. Specialized interviewing techniques pertaining to assessment in this unique population are discussed. Evidence-based guidelines for management of pediatric depression in terms of both pharmacotherapy and psychotherapy are also enumerated. Choice of medication based on multiple parameters with available evidence base is discussed. Treatment planning and continued evaluation on long-term basis are also elaborated.
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Affiliation(s)
- Suravi Patra
- Department of Psychiatry, AIIMS, Bhubaneswar, Odisha, India
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Strawn JR, Mills JA, Croarkin PE. Switching Selective Serotonin Reuptake Inhibitors in Adolescents with Selective Serotonin Reuptake Inhibitor-Resistant Major Depressive Disorder: Balancing Tolerability and Efficacy. J Child Adolesc Psychopharmacol 2019; 29:250-255. [PMID: 30810350 PMCID: PMC6534091 DOI: 10.1089/cap.2018.0145] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: To guide clinicians in selecting the "next line" selective serotonin reuptake inhibitor (SSRI) for adolescents with treatment-resistant major depressive disorder, we sought to compare response rates among SSRIs in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study and to jointly model tolerability and efficacy for the specific SSRI comparisons. Methods: Efficacy and tolerability data for paroxetine, citalopram, and fluoxetine were extracted from the TORDIA study. Using a joint bivariate normal likelihood for response and tolerability (based on the maximum implied variance from the 95% credible intervals previously reported for the three SSRIs), a Monte Carlo pseudorandom sample (100,000 draws) was obtained, from which credible intervals, means, posterior tail probabilities, etc. were determined. Joint null hypotheses of no difference in efficacy and tolerability were then evaluated with regard to superiority of each SSRI over the others. Results: No significant differences in response were observed for citalopram compared with fluoxetine (p = 0.247) or for fluoxetine compared with paroxetine (p = 0.110), although citalopram trended toward being superior to paroxetine (mean difference: 0.2, p = 0.055). For efficacy-tolerability models, citalopram and fluoxetine were superior to paroxetine (p = 0.029 and p = 0.022, respectively) but did not differ between each other (p = 0.146). Conclusions: Joint efficacy-tolerability models suggest that citalopram and fluoxetine were statistically significantly superior to paroxetine while citalopram trended toward superiority over paroxetine in the efficacy model. These findings provide a more granular and practical evidence base for clinicians faced with treatment sequencing decisions in adolescents with SSRI-resistant depression.
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Affiliation(s)
- Jeffrey R. Strawn
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Division of Child and Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Address correspondence to: Jeffrey R. Strawn, MD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Box 670559, Cincinnati, OH 45267-0559
| | - Jeffrey A. Mills
- Carl H. Lindner College of Business, University of Cincinnati, Cincinnati, Ohio
| | - Paul E. Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
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Estimating patient-specific treatment advantages in the 'Treatment for Adolescents with Depression Study'. J Psychiatr Res 2019; 112:61-70. [PMID: 30856378 DOI: 10.1016/j.jpsychires.2019.02.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 01/12/2019] [Accepted: 02/25/2019] [Indexed: 11/23/2022]
Abstract
The 'Treatment for Adolescents with Depression Study' (TADS, ClinicalTrials.gov, identifier: NCT00006286) was a cornerstone, randomized controlled trial evaluating the effectiveness of standard treatment options for major depression in adolescents. Whereas previous TADS analyses examined primarily effect modifications of treatment-placebo differences by various patient characteristics, less is known about the modification of inter-treatment differences, and hence, patient characteristics that might guide treatment selection. We sought to fill this gap by estimating patient-specific inter-treatment differences as a function of patients' baseline characteristics. We did so by applying the 'model-based random forest', a recently-introduced machine learning-based method for evaluating effect heterogeneity that allows for the estimation of patient-specific treatment effects as a function of arbitrary baseline characteristics. Treatment conditions were cognitive-behavioural therapy (CBT) alone, fluoxetine (FLX) alone, and the combination of CBT and fluoxetine (COMB). All inter-treatment differences (CBT vs. FLX; CBT vs. COMB; FLX vs. COMB) were evaluated across 23 potential effect modifiers extracted from previous studies. Overall, FLX was superior to CBT, while COMB was superior to both CBT and FLX. Evidence for effect heterogeneity was found for the CBT-FLX difference and the FLX-COMB difference, but not for the CBT-COMB difference. Baseline depression severity modified the CBT-FLX difference; whereas baseline depression severity, patients' treatment expectations, and childhood trauma modified the FLX-COMB difference. All modifications were quantitative rather than qualitative, however, meaning that the differences varied only in magnitude, but not direction. These findings imply that combining CBT with fluoxetine may be superior to either therapy used alone across a broad range of patients.
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Rootes-Murdy K, Carlucci M, Tibbs M, Wachtel LE, Sherman MF, Zandi PP, Reti IM. Non-suicidal self-injury and electroconvulsive therapy: Outcomes in adolescent and young adult populations. J Affect Disord 2019; 250:94-98. [PMID: 30844603 DOI: 10.1016/j.jad.2019.02.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/17/2018] [Accepted: 02/24/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Electroconvulsive (ECT) therapy is a highly effective treatment for severe depression. Although the clear majority of patients respond to ECT, not all do, and we still lack good predictors for ECT outcome, especially in adolescents and young adults. One clinical variable that has been associated with reduced likelihood of ECT antidepressant response in adults is comorbid borderline personality disorder. As self-injurious behavior is often a feature of borderline personality disorder, we hypothesized that adolescent and young adult patients with a history of non-suicidal self-injury (NSSI), who were being treated for major depression with ECT, would have a poorer response than patients without such a history. METHODS We conducted a retrospective chart review of 48 patients treated with ECT for depression at The Johns Hopkins Hospital between the ages of 14 and 25. RESULTS Initial analyses showed that the presence of NSSI was not associated with ECT outcomes. However, sub-group analyses suggested that it was associated with response to ECT and overall remission among female patients. Specifically, the results suggested that in adolescent and young adult female ECT patients, the presence of NSSI was associated with lower odds of response (OR: 0.04; 95% CI: 0.0004, 0.81, p = 0.03) and remission (OR: 0.09; 95% CI: 0.0000, 0.81, p = 0.03), and a greater mean number of treatments (5.83; 95% CI: 0.27, 11.39, p = 0.04) compared with patients without NSSI. CONCLUSIONS Clearly, the finding that NSSI may be associated with poorer ECT outcomes among female patients needs to be replicated. Nonetheless, our data suggest caution when considering an adolescent or young adult woman for a course of ECT.
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Affiliation(s)
- Kelly Rootes-Murdy
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States; Loyola University Maryland, Baltimore, MD, United States
| | | | - Michael Tibbs
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lee E Wachtel
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Peter P Zandi
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - Irving M Reti
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Goodyer IM, Wilkinson PO. Practitioner Review: Therapeutics of unipolar major depressions in adolescents. J Child Psychol Psychiatry 2019; 60:232-243. [PMID: 29939396 DOI: 10.1111/jcpp.12940] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Over the past two decades new and key randomized controlled trials have reported the efficacy, clinical and cost effectiveness of psychological and pharmacological treatments for adolescents with major depression. METHODS The literature was searched through pubmed, psychinfo, scopus and web of science for randomized controlled trials of current major depression together with meta-analyses and systematic reviews of trials between 2000 and 2017. Those specific to the adolescent years (11-18 years) were taken as the primary source for this narrative review. Additional selected studies in adults were used to illustrate methodological issues. RESULTS Manualized psychological therapies and the SSRI fluoxetine are more effective than active placebo in the treatment of major depressions. Mild to moderate illnesses attending community-based services are likely to benefit from psychological treatment alone. Moderately to severely ill patients attending clinic and hospital services are likely to benefit from monotherapies or combining psychological and pharmacological treatment. Antidepressants carry a small but significant side-effect risk including increased suicidality. Side effects from psychotherapies are somewhat lower but specific negative consequences remain less well characterized. There is some evidence that CBT-based approaches prevent onset of major depression episode in well adolescents at high-risk. Other psychological interventions have not been adequately studied. There has been only limited identification of treatment moderators and no clear understanding of therapeutic mechanisms. CONCLUSIONS There is now a range of clinically effective treatments for depressed adolescents. Future research needs to reveal moderators of and mechanisms for individual differences to treatment response, determine psychotherapies of value for milder depressions, enhance our understanding of safety and side-effects for all treatments, and consider how to reduce and treat treatment-resistant cases.
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Affiliation(s)
- Ian M Goodyer
- Developmental Psychiatry, Department of Psychiatry, University of Cambridge Clinical School, Cambridge, UK
| | - Paul O Wilkinson
- Developmental Psychiatry, Department of Psychiatry, University of Cambridge Clinical School, Cambridge, UK
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Monsour A, Mew EJ, Szatmari P, Patel S, Saeed L, Offringa M, Butcher NJ. Outcomes reported in randomised clinical trials of major depressive disorder treatments in adolescents: a systematic scoping review protocol. BMJ Open 2019; 9:e024191. [PMID: 30782729 PMCID: PMC6340428 DOI: 10.1136/bmjopen-2018-024191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/19/2018] [Accepted: 11/22/2018] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Major depressive disorder (MDD) is a common mental health condition in adolescents. Randomised clinical trials (RCTs) are the gold standard for assessing the safety and efficacy of interventions in this population. Heterogeneity in the outcomes measured and reported between RCTs limits the ability to compare, contrast, and combine trial results in a clinically meaningful way. There is currently no core outcome set (COS) available for use in RCTs evaluating interventions in adolescents with MDD. We will conduct a systematic scoping review of outcomes reported in adolescent depression RCTs to assess the variability of trial outcomes and to inform the development of a COS for adolescent MDD. METHODS AND ANALYSIS We will apply methods based on the Joanna Briggs Institute scoping review methods manual. RCTs evaluating any treatment intervention for adolescent MDD published in the last 10 years will be located using an electronic bibliographic database search (MEDLINE, PsycINFO and Cochrane Central Register of Controlled Trials). Title and abstract screening, full-text screening, and data charting of eligible studies will be performed in duplicate. Outcomes identified will be mapped to an outcome-domain framework. Data analysis will include summary statistics of the characteristics of the included trials and outcomes. ETHICS AND DISSEMINATION The results of this review will inform the development of a COS for adolescent MDD. The development and implementation of a COS for RCTs evaluating interventions in adolescents with MDD promise to help reduce variability in trial outcome selection, definition, measurement and reporting, ultimately facilitating evidence synthesis that will help to identify the best treatment practices for adolescents with MDD.
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Affiliation(s)
- Andrea Monsour
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Emma J Mew
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Peter Szatmari
- Cundill Centre for Child and Youth Depression at the Centre for Addiction and Mental Health, and Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sagar Patel
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Leena Saeed
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Nancy J Butcher
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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Review: What Outcomes Count? A Review of Outcomes Measured for Adolescent Depression Between 2007 and 2017. J Am Acad Child Adolesc Psychiatry 2019; 58:61-71. [PMID: 30577940 DOI: 10.1016/j.jaac.2018.07.893] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/03/2018] [Accepted: 08/15/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Measurement of treatment outcomes in childhood depression has traditionally focused on assessing symptoms from the clinician's perspective, without exploring other outcome domains or considering young people's perspectives. This systematic review explored the extent to which multidimensional and multi-informant outcome measurements have been used in clinical research for adolescent depression in the past decade and how patterns have evolved over time. METHOD Embase, Medline, and PsycINFO were searched, and studies that were published from 2007 through 2017 and assessed the effectiveness of treatments or service provision for adolescent depression were included. Of 7,483 studies screened, 95 met the inclusion criteria and were included for data extraction and analysis. RESULTS Ten outcomes domains were identified, 2 of which were assessed on average using 4 outcome measures. Most studies (94%) measured symptoms, followed by functioning (52%). Other domains such as personal growth, relationships, quality of life, and service satisfaction were each considered by less than 1 in 10 studies. Youth self-report was considered by 54% but tended to focus on secondary outcomes. Multidimensional and multi-informant measurements were more frequent in studies published since 2015. CONCLUSION Recent clinical research continues to prioritize symptoms measurement based on clinician report and has not yet fully embraced multidimensional and multi-informant approaches. In the context of significant policy shifts toward patient-centered and evidence-based care, measuring what matters most to patients has become a priority, but this is not yet widely reflected in clinical research.
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Gunlicks-Stoessel M, Mufson L, Bernstein G, Westervelt A, Reigstad K, Klimes-Dougan B, Cullen K, Murray A, Vock D. Critical Decision Points for Augmenting Interpersonal Psychotherapy for Depressed Adolescents: A Pilot Sequential Multiple Assignment Randomized Trial. J Am Acad Child Adolesc Psychiatry 2019; 58:80-91. [PMID: 30577943 PMCID: PMC7549148 DOI: 10.1016/j.jaac.2018.06.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 05/25/2018] [Accepted: 06/21/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Practice parameters recommend systematic assessment of depression symptoms over the course of treatment to inform treatment planning; however, there are currently no guidelines regarding how to use symptom monitoring to guide treatment decisions for psychotherapy. The current study compared two time points (week 4 and week 8) for assessing symptoms during interpersonal psychotherapy for depressed adolescents (IPT-A) and explored four algorithms that use the symptom assessments to select the subsequent treatment. METHOD Forty adolescents (aged 12-17 years) with a depression diagnosis began IPT-A with an initial treatment plan of 12 sessions delivered over 16 weeks. Adolescents were randomized to a week 4 or week 8 decision point for considering a change in treatment. Insufficient responders at either time point were randomized a second time to increased frequency of IPT-A (twice per week) or addition of fluoxetine. Measures were administered at baseline and weeks 4, 8, 12, and 16. RESULTS The week 4 decision point for assessing response and implementing treatment augmentation for insufficient responders was more efficacious for reducing depression symptoms than the week 8 decision point. There were significant differences between algorithms in depression and psychosocial functioning outcomes. CONCLUSION Therapists implementing IPT-A should routinely monitor depression symptoms and consider augmenting treatment for insufficient responders as early as week 4 of treatment. CLINICAL TRIAL REGISTRATION INFORMATION An Adaptive Treatment Strategy for Adolescent Depression. https://clinicaltrials.gov; NCT02017535.
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Affiliation(s)
| | - Laura Mufson
- Columbia University College of Physicians & Surgeons and New York State Psychiatric Institute, New York, NY
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129
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Grover S, Avasthi A. Clinical Practice Guidelines for the management of depression in children and adolescents. Indian J Psychiatry 2019; 61:226-240. [PMID: 30745698 PMCID: PMC6345140 DOI: 10.4103/psychiatry.indianjpsychiatry_563_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Ajit Avasthi
- Department of Psychiatry, PGIMER, Chandigarh, India
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130
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Coppola G, Operto FF, Matricardi S, Verrotti A. Monitoring And Managing Depression In Adolescents With Epilepsy: Current Perspectives. Neuropsychiatr Dis Treat 2019; 15:2773-2780. [PMID: 31576132 PMCID: PMC6765392 DOI: 10.2147/ndt.s192714] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 09/02/2019] [Indexed: 11/23/2022] Open
Abstract
Epilepsy is associated with a significantly increased risk of developing depressive disorder during adolescence. On the other hand, depression is highly detected in adolescents with epilepsy. These findings highlight the importance of early identification and proper management of comorbid depression in adolescent age. The prevalence of depressive disorders in adolescents with epilepsy ranges between 8 and 35% and is higher than the general population of the same age. The relationship between epilepsy and depression is complex and potentially bidirectional, thereby suggesting a common underlying pathophysiology. Furthermore, failure to detect and treat depressive disorder mostly in adolescence could lead to several negative implications such as an increased risk of suicidal ideation or behavior and poor quality of life. A number of methods are available to detect depressive disorder, such as psychiatric or psychological assessments, structured or semi-structured interviews, and self-report screening tools. Thus, physicians should be able to regularly screen depressive symptoms in youths with epilepsy. Recently, the NDDI-E-.Y inventory has been developed from the adult NDDI-E, and has been validated in many countries. NDDI-E-Y has showed reliable validity, being a brief screening tool (12 items) that can be easily included in routine epilepsy care. The first step to be considered for the management of depressive disorder in adolescents with epilepsy is to consider potential reversible causes of anxiety and depression (i.e., a new AEDs; seizure control). Secondly, great attention has to be given to the education of the child/adolescent and his/her family, trying to improve knowledge about epilepsy as well as to decrease parental stress and improving the child's sense of competence. Pharmacological treatment should also be considered in adolescents diagnosed with depression.
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Affiliation(s)
- Giangennaro Coppola
- Child and Adolescent Neuropsychiatry, Department of Medicine, Surgery, and Odontoiatry, University of Salerno, Salerno, Italy
| | - Francesca Felicia Operto
- Child and Adolescent Neuropsychiatry, Department of Medicine, Surgery, and Odontoiatry, University of Salerno, Salerno, Italy
| | - Sara Matricardi
- Department of Pediatric Neurology, Ospedali Riuniti, Ancona, Italy
| | - Alberto Verrotti
- Department of Pediatrics, University of L'Aquila, L'Aquila, Italy
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131
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Foster S, Mohler-Kuo M. Treating a broader range of depressed adolescents with combined therapy. J Affect Disord 2018; 241:417-424. [PMID: 30145512 DOI: 10.1016/j.jad.2018.08.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/26/2018] [Accepted: 08/07/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Traditional statistical analyses of clinical trials encompass the central tendency of outcomes and, hence, are restricted to a treatment's average effectiveness. Our aim was to get a more complete picture of the effectiveness of standard treatment options for adolescent depression, by analyzing treatment effects across low, middle, and high levels of response. METHODS Secondary data analysis was performed of the Treatment for Adolescents with Depression Study (TADS, ClinicalTrials.gov, NCT00006286), a randomized controlled trial comparing fluoxetine (FLX), cognitive-behavioral therapy (CBT), and their combination (COMB) against placebo treating adolescents with major depression (n = 439). The proportional change from baseline to week 12 in the Children's Depression Rating Scale-Revised was used as an index of response. Response levels were analyzed via quantile regression models, thereby estimating treatment effects across the entire response level distribution, adjusted for baseline depression, study site, and patients' treatment expectancies. RESULTS Whereas CBT was no more effective than placebo across response levels, COMB was more effective than FLX in that its quantile treatment effects were both larger in magnitude and spread out across a broader range of response levels, including the low end of the response level distribution. Cohen's d of the difference was 1.39 (95% confidence interval 1.33-1.45). LIMITATIONS Ad-hoc analysis using data from a trial that was not originally designed to accommodate such analysis. CONCLUSION The combination of cognitive-behavioral therapy and fluoxetine was more effective than either treatment used alone, not just in average effectiveness, but in the breadth of patients in whom it was effective.
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Affiliation(s)
- Simon Foster
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001 Zürich, Switzerland; Swiss Research Institute for Public Health and Addiction associated with the University of Zurich, Konradstrasse 32, 8031 Zurich, Switzerland.
| | - Meichun Mohler-Kuo
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, 8001 Zürich, Switzerland; Swiss Research Institute for Public Health and Addiction associated with the University of Zurich, Konradstrasse 32, 8031 Zurich, Switzerland; La Source, School of Nursing Sciences, HES-SO University of Applied Sciences and Arts of Western Switzerland, Av. Vinet 30, 1004 Lausanne, Switzerland
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132
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Vitiello B, Davico C. Twenty years of progress in paediatric psychopharmacology: accomplishments and unmet needs. EVIDENCE-BASED MENTAL HEALTH 2018; 21:e10. [PMID: 30352885 PMCID: PMC10270463 DOI: 10.1136/ebmental-2018-300040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 09/29/2018] [Accepted: 10/02/2018] [Indexed: 01/12/2023]
Abstract
The systematic assessment of the efficacy and safety of psychiatric medications in children and adolescents started about 20 years ago. Since then, a considerable number of randomised clinical trials have been conducted, including also a series of publicly funded comparative effectiveness studies to evaluate the therapeutic benefit of medications relative to psychosocial interventions, alone or combined with medications. On the whole, these studies have been informative of the paediatric pharmacokinetics, efficacy and safety of the most commonly used psychotropics. As a consequence, a number of meta-analyses have been conducted that have documented both the benefits and harms of the most common medication groups, such as stimulants, antidepressants and antipsychotics. Evidence-based practice guidelines have been produced, and clinicians can now better estimate the therapeutic value and the risk of treatment, at least at the group mean level. However, most clinical trials have been conducted in research settings, and this limits the generalisability of the results. There is a need for evaluating treatment effects under usual practice conditions, through practical trials. The ongoing debate about the proper role of pharmacotherapy in child mental health can be advanced by comparative effectiveness research to assess the benefit/risk ratio of pharmacotherapy vis-à-vis alternative treatment modalities. In addition, analyses of large population databases can better inform on the impact of early treatment on important distal outcomes, such as interpersonal functioning, social and occupational status, quality of life and risk for disability or mortality. Thus far, paediatric psychopharmacology has been mostly the application to children of medications that were serendipitously discovered and developed for adults. By focusing on the neurobiological mechanisms of child psychopathology, it may be possible to identify more precise pharmacological targets and arrive at a truly developmental psychopharmacology.
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Affiliation(s)
- Benedetto Vitiello
- Division of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Science, University of Turin, Turin, Italy
| | - Chiara Davico
- Division of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatric Science, University of Turin, Turin, Italy
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Abstract
Major depressive disorder (MDD) is one of the most common psychiatric disorders of childhood and adolescence, but because of symptom variation from the adult criteria, it is often unrecognized and untreated. Symptom severity predicts the initial mode of treatment ranging from psychotherapy to medications to combination treatment. Several studies have assessed the efficacy of treatment in children and adolescents, and others have evaluated the risk of developing adverse effects and/or new or worsening suicidal thoughts and behaviors. Optimal treatment often includes a combination of therapy and antidepressant medication. The most studied combination includes fluoxetine with cognitive behavioral therapy. Once symptom remission is obtained, treatment should be continued for 6 to 12 months before a slow taper is initiated. Although most children and adolescents recover from their first depressive episode, a large number will continue to present with MDD in adulthood. Untreated depression in children and adolescents may increase the risk of substance abuse; poor work, academic, and social functioning; and risk of suicidal behaviors.
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Affiliation(s)
- Sandra Mullen
- (Corresponding author) Clinical Pharmacy Specialist-Psychiatry, VCU Health Systems, Richmond, Virginia,
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134
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Calarge CA, Mills JA, Karaviti L, Teixeira AL, Zemel BS, Garcia JM. Selective Serotonin Reuptake Inhibitors Reduce Longitudinal Growth in Risperidone-Treated Boys. J Pediatr 2018; 201:245-251. [PMID: 29958671 PMCID: PMC6153035 DOI: 10.1016/j.jpeds.2018.05.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 04/12/2018] [Accepted: 05/22/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To examine whether selective serotonin reuptake inhibitors (SSRIs) inhibit longitudinal growth in children and adolescents, particularly in the early stages of puberty, using a sample of convenience comprising risperidone-treated boys. STUDY DESIGN Data from four clinic-based studies in risperidone-treated 5- to 17-year-old boys with no general medical conditions were combined for this analysis. Anthropometric measurements and psychotropic treatment history were extracted from the medical and pharmacy records. Linear mixed effects regression analyses examined the association between SSRI use and change in age-sex-specific height and body mass index z scores, after adjusting for relevant confounders. RESULTS Risperidone-treated boys (n = 267; age: 12.7 ± 2.7 years), 71% of whom had ever taken an SSRI, contributed to the analysis. After adjusting for age, psychostimulant and antipsychotic use, and time in the study, both the duration of SSRI use as well as the cumulative dose were inversely associated with height z score after age 11 years (P < .0001). After adjusting for baseline height, duration of SSRI use was most strongly inversely associated with height z score in Tanner stages 3 and 4 boys who took SSRIs continuously (r = -0.69, P < .009). No association was observed with body mass index z score. CONCLUSIONS In risperidone-treated boys, SSRI use is associated with reduced longitudinal growth, particularly in those undergoing puberty. Whether adult height or other metabolic or psychological outcomes are affected remains to be determined.
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Affiliation(s)
- Chadi A. Calarge
- Menninger Department of Psychiatry and Behavioral Science and Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Street, Suite 1740, Houston, TX 77030-2399, Tel: 832-824-4764, Fax: 832-825-8981,
| | - James A. Mills
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Antonio L. Teixeira
- Department of Psychiatry, The University of Texas Health Science Center at Houston, Houston, TX
| | - Babette S. Zemel
- Department of Pediatrics, The University of Pennsylvania, Philadelphia, PA
| | - Jose M. Garcia
- Department of Internal Medicine, The University of Washington, Seattle, WA
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135
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Cullen KR, Amatya P, Roback MG, Albott CS, Westlund Schreiner M, Ren Y, Eberly LE, Carstedt P, Samikoglu A, Gunlicks-Stoessel M, Reigstad K, Horek N, Tye S, Lim KO, Klimes-Dougan B. Intravenous Ketamine for Adolescents with Treatment-Resistant Depression: An Open-Label Study. J Child Adolesc Psychopharmacol 2018; 28:437-444. [PMID: 30004254 PMCID: PMC6154760 DOI: 10.1089/cap.2018.0030] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Novel interventions for treatment-resistant depression (TRD) in adolescents are urgently needed. Ketamine has been studied in adults with TRD, but little information is available for adolescents. This study investigated efficacy and tolerability of intravenous ketamine in adolescents with TRD, and explored clinical response predictors. METHODS Adolescents, 12-18 years of age, with TRD (failure to respond to two previous antidepressant trials) were administered six ketamine (0.5 mg/kg) infusions over 2 weeks. Clinical response was defined as a 50% decrease in Children's Depression Rating Scale-Revised (CDRS-R); remission was CDRS-R score ≤28. Tolerability assessment included monitoring vital signs and dissociative symptoms using the Clinician-Administered Dissociative States Scale (CADSS). RESULTS Thirteen participants (mean age 16.9 years, range 14.5-18.8 years, eight biologically male) completed the protocol. Average decrease in CDRS-R was 42.5% (p = 0.0004). Five (38%) adolescents met criteria for clinical response. Three responders showed sustained remission at 6-week follow-up; relapse occurred within 2 weeks for the other two responders. Ketamine infusions were generally well tolerated; dissociative symptoms and hemodynamic symptoms were transient. Higher dose was a significant predictor of treatment response. CONCLUSIONS These results demonstrate the potential role for ketamine in treating adolescents with TRD. Limitations include the open-label design and small sample; future research addressing these issues are needed to confirm these results. Additionally, evidence suggested a dose-response relationship; future studies are needed to optimize dose. Finally, questions remain regarding the long-term safety of ketamine as a depression treatment; more information is needed before broader clinical use.
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Affiliation(s)
- Kathryn R. Cullen
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota.,Address correspondence to: Kathryn R. Cullen, MD, Division of Child and Adolescent Psychiatry, Department of Psychiatry, Medical School, University of Minnesota, 2450 Riverside Avenue, Minneapolis, MN 55454
| | - Palistha Amatya
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Mark G. Roback
- Departments of Pediatrics and Emergency Medicine, Medical School, University of Minnesota, Minneapolis, Minnesota
| | - Christina Sophia Albott
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | | | - Yanan Ren
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Lynn E. Eberly
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Patricia Carstedt
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Ali Samikoglu
- Hennepin County Medical Center, Minneapolis, Minnesota
| | - Meredith Gunlicks-Stoessel
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Kristina Reigstad
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Nathan Horek
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | | | - Kelvin O. Lim
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Bonnie Klimes-Dougan
- Psychology Department, College of Liberal Arts, University of Minnesota, Minneapolis, Minnesota
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136
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Goodyer IM. Editorial Perspective: Antidepressants and the depressed adolescent. Child Adolesc Ment Health 2018; 23:137-140. [PMID: 32677291 DOI: 10.1111/camh.12291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A paper considering the role of antidepressants for adults with major depression was recently published in the Lancet, a world leading medical journal (Cipriani et al. 2018). The review was the largest ever on this topic based on 28,552 citations including 522 trials comprising 116,477 participants. The authors note that, in adults with major depression, all antidepressants were more efficacious than placebo. In head-to-head studies, the authors also note that agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were more effective than other antidepressants whereas fluoxetine, fluvoxamine, reboxetine, and trazodone were the least efficacious. The authors report that the standardised mean difference was 0.3 a moderate effect size for any antidepressant over placebo, this is confirmatory of past reviews noting rather similar magnitudes of effect. In clinical terms the results suggest a choice for practitioners in regard to their individual patients. For many adult depressed patients however, there is also the implication that antidepressants may not work. The old adage 'what works for whom' remains unanswered. What does seem reasonable to conclude is that we have learnt that these medications are clinically effective and the questions for research now must be who is likely to benefit and who is not, how do these medicines work, and what is the best long-term management of responders as the majority of studies have focused on acute response only.
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Affiliation(s)
- Ian M Goodyer
- Department of Psychiatry, Cambridge University Clinical School, Cambridge, UK
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137
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Umemori J, Winkel F, Didio G, Llach Pou M, Castrén E. iPlasticity: Induced juvenile-like plasticity in the adult brain as a mechanism of antidepressants. Psychiatry Clin Neurosci 2018; 72:633-653. [PMID: 29802758 PMCID: PMC6174980 DOI: 10.1111/pcn.12683] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2018] [Indexed: 12/11/2022]
Abstract
The network hypothesis of depression proposes that mood disorders reflect problems in information processing within particular neural networks. Antidepressants (AD), including selective serotonin reuptake inhibitors (SSRI), function by gradually improving information processing within these networks. AD have been shown to induce a state of juvenile-like plasticity comparable to that observed during developmental critical periods: Such critical-period-like plasticity allows brain networks to better adapt to extrinsic and intrinsic signals. We have coined this drug-induced state of juvenile-like plasticity 'iPlasticity.' A combination of iPlasticity induced by chronic SSRI treatment together with training, rehabilitation, or psychotherapy improves symptoms of neuropsychiatric disorders and issues underlying the developmentally or genetically malfunctioning networks. We have proposed that iPlasticity might be a critical component of AD action. We have demonstrated that iPlasticity occurs in the visual cortex, fear erasure network, extinction of aggression caused by social isolation, and spatial reversal memory in rodent models. Chronic SSRI treatment is known to promote neurogenesis and to cause dematuration of granule cells in the dentate gyrus and of interneurons, especially parvalbumin interneurons enwrapped by perineuronal nets in the prefrontal cortex, visual cortex, and amygdala. Brain-derived neurotrophic factor (BDNF), via its receptor tropomyosin kinase receptor B, is involved in the processes of synaptic plasticity, including neurogenesis, neuronal differentiation, weight of synapses, and gene regulation of synaptic formation. BDNF can be activated by both chronic SSRI treatment and neuronal activity. Accordingly, the BDNF/tropomyosin kinase receptor B pathway is critical for iPlasticity, but further analyses will be needed to provide mechanical insight into the processes of iPlasticity.
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Affiliation(s)
- Juzoh Umemori
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
| | - Frederike Winkel
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
| | - Giuliano Didio
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
| | - Maria Llach Pou
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
| | - Eero Castrén
- Neuroscience Center, HiLIFEUniversity of HelsinkiHelsinkiFinland
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138
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Menezes M, Robinson L, Sanchez MJ, Cook B. Depression in Youth with Autism Spectrum Disorders: a Systematic Review of Studies Published Between 2012 and 2016. REVIEW JOURNAL OF AUTISM AND DEVELOPMENTAL DISORDERS 2018. [DOI: 10.1007/s40489-018-0146-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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139
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Hussain H, Dubicka B, Wilkinson P. Recent developments in the treatment of major depressive disorder in children and adolescents. EVIDENCE-BASED MENTAL HEALTH 2018; 21:101-106. [PMID: 30045844 PMCID: PMC10270457 DOI: 10.1136/eb-2018-102937] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 05/31/2018] [Accepted: 06/04/2018] [Indexed: 01/22/2023]
Abstract
Major depressive disorder in adolescents is an important public health concern. It is common, a risk factor for suicide and is associated with adverse psychosocial consequences. The UK National Institute for Health and Care Excellence guidelines recommend that children and young people with moderate-to-severe depression should be seen within Child and Adolescent Mental Health Services and receive specific psychological interventions, possibly in combination with antidepressant medication. Cognitive behavioural therapy (in some studies) and interpersonal psychotherapy have been demonstrated to be more effective than active control treatments for depressed adolescents. For children with depression, there is some evidence that family focused approaches are more effective than individual therapy. Fluoxetine is the antidepressant with the greatest evidence for effectiveness compared with placebo. Treatment with antidepressants and/or psychological therapy is likely to reduce suicidality, although in some young people, selective serotonin reuptake inhibitors lead to increased suicidality. There is limited evidence that combination of specific psychological therapy and antidepressant medication is better than treatment with monotherapy. There are methodological limitations in the published literature that make it difficult to relate study findings to the more severely ill clinical population in Child and Adolescent Mental Health Services. Young people should have access to both evidence-based psychological interventions and antidepressants for paediatric depression. Collaborative decisions on treatment should be made jointly by young people, their carers and clinicians, taking into account individual circumstances and potential benefits, risks and availability of treatment.
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Affiliation(s)
- Haseena Hussain
- Academic Clinical Fellow and Specialty Registrar in Child and Adolescent Psychiatry, University of Cambridge and Hertfordshire Partnership University NHS Foundation Trust, Cambridge, UK
| | - Bernadka Dubicka
- Consultant Child and Adolescent Psychiatrist, Pennine Care Foundation trust and honorary reader, University of Manchester, UK
| | - Paul Wilkinson
- Consultant and clinical Lecturer in Child and Adolescent Psychiatry, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
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140
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Lewis CP, Nakonezny PA, Blacker CJ, Vande Voort JL, Port JD, Worrell GA, Jo HJ, Daskalakis ZJ, Croarkin PE. Cortical inhibitory markers of lifetime suicidal behavior in depressed adolescents. Neuropsychopharmacology 2018; 43:1822-1831. [PMID: 29703993 PMCID: PMC6046050 DOI: 10.1038/s41386-018-0040-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 01/05/2018] [Accepted: 02/26/2018] [Indexed: 11/09/2022]
Abstract
Although suicide is the second-leading cause of death in adolescents and young adults worldwide, little progress has been made in developing reliable biological markers of suicide risk and suicidal behavior. Converging evidence suggests that excitatory and inhibitory cortical processes mediated by the neurotransmitters glutamate and γ-aminobutyric acid (GABA) are dysregulated in suicidal individuals. This study utilized single- and paired-pulse transcranial magnetic stimulation (TMS) to assess excitatory and inhibitory cortical functioning in healthy control adolescents (n = 20), depressed adolescents without any history of suicidal behavior ("Depressed", n = 37), and depressed adolescents with lifetime history of suicidal behavior ("Depressed+SB", n = 17). In a fixed-effects general linear model analysis, with age, sex, and depression severity as covariates, no significant group main effects emerged for resting motor threshold, intracortical facilitation, short-interval intracortical inhibition, or cortical silent period. However, group main effects were significant for long-interval intracortical inhibition (LICI) at interstimulus intervals (ISIs) of 100 ms and 150 ms, but not 200 ms. Depressed+SB adolescents demonstrated impaired LICI compared to healthy control and Depressed adolescents, while healthy control and Depressed participants did not differ in LICI. Multiple linear robust regression revealed significant positive linear relationships between lifetime suicidal behavior severity and impairment in LICI at 100-ms and 150-ms ISIs. In a post hoc receiver operating characteristic analysis, LICI significantly discriminated Depressed from Depressed+SB youth in 100-ms and 150-ms paradigms. These findings suggest that GABAB receptor-mediated inhibition is distinctly dysregulated in depressed adolescents with histories of suicidal behavior. Further research is warranted to establish the utility of cortical inhibition in the assessment of suicide risk and as a target for treatment interventions.
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Affiliation(s)
- Charles P Lewis
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Paul A Nakonezny
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Clinical Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Caren J Blacker
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | | | - John D Port
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Hang Joon Jo
- Department of Neurologic Surgery, Neural Engineering Lab, Mayo Clinic, Rochester, MN, USA
| | - Zafiris J Daskalakis
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Temerty Centre for Therapeutic Brain Intervention, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA.
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141
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Crookes DM, Demmer RT, Keyes KM, Koenen KC, Suglia SF. Depressive Symptoms, Antidepressant Use, and Hypertension in Young Adulthood. Epidemiology 2018; 29:547-555. [PMID: 29629939 PMCID: PMC5980764 DOI: 10.1097/ede.0000000000000840] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Among adults, depressive symptoms are associated with higher rates of cardiovascular disease; however, the evidence is mixed regarding the association between depressive symptoms and hypertension, especially among young adults. The deleterious effects of some antidepressant medications on blood pressure may contribute to mixed findings. METHODS Adolescents enrolled in Add Health (N = 11,183) (1994-2008) completed an abbreviated Center for Epidemiologic Studies Depression Scale at three waves (mean ages, 16, 22, and 29). Antidepressant use was measured at age 22 and at age 29. Hypertension at age 29 was defined as measured systolic blood pressure of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater, or staff-inventoried anti-hypertensive medication use. RESULTS The prevalence of hypertension at age 29 was 20%. High depressive symptoms in adolescence or young adulthood were not associated with hypertension in young adulthood. Antidepressant use at age 29 was associated with increased prevalence of hypertension (prevalence ratio [PR], 1.4; 95% CI, 1.2, 1.7) and an interaction with sex was observed (PRMen, 1.6; 95% CI, 1.2, 2.0; PRWomen, 1.2; 95% CI, 0.89, 1.6; pinteraction = 0.0227). Selective serotonin reuptake inhibitor and non-selective serotonin reuptake inhibitor antidepressant use were associated with hypertension (PRSSRI, 1.3; 95% CI, 1.0, 1.6; PRnon-SSRI, 1.6; 95% CI, 1.2, 2.1). CONCLUSIONS In this sample, antidepressant use, but not depressive symptoms, was associated with hypertension in young adulthood. Further research is recommended to examine joint and independent relationships between depression and antidepressant use and hypertension among young adults. See video abstract at, http://links.lww.com/EDE/B355.
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Affiliation(s)
- Danielle M. Crookes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Ryan T. Demmer
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Katherine M. Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Karestan C. Koenen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA
| | - Shakira F. Suglia
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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142
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Gabbay V, Freed RD, Alonso CM, Senger S, Stadterman J, Davison BA, Klein RG. A Double-Blind Placebo-Controlled Trial of Omega-3 Fatty Acids as a Monotherapy for Adolescent Depression. J Clin Psychiatry 2018; 79:17m11596. [PMID: 29985566 PMCID: PMC6625364 DOI: 10.4088/jcp.17m11596] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 11/13/2017] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Reports are mixed on the efficacy of omega-3 fatty acids (O3FA) for the treatment of major depressive disorder (MDD), with only limited data in adolescents. The present trial aimed to investigate systematically the efficacy of O3FA as a monotherapy, compared to a placebo, in adolescents with MDD. Secondarily, we explored O3FA effects on anhedonia, irritability, and suicidality-all key features of adolescent MDD. METHODS Fifty-one psychotropic medication-free adolescents with DSM-IV-TR diagnoses of MDD (aged 12-19 years; 57% female) were randomized to receive O3FA or a placebo for 10 weeks. Data were collected between January 2006 and June 2013. O3FA and a placebo were administered on a fixed-flexible dose titration schedule based on clinical response and side effects. The initial dose of 1.2 g/d was increased 0.6 g/d every 2 weeks, up to a maximum of 3.6 g/d. Clinician-rated and self-rated depression severity, along with treatment response, served as primary outcome measures. Additionally, we examined O3FA effects on depression-related symptoms, including anhedonia, irritability, and suicidality. Treatment differences were analyzed via intent-to-treat analyses. RESULTS O3FA were not superior to a placebo on any clinical feature, including depression severity and levels of anhedonia, irritability, or suicidality. Additionally, response rates were comparable between treatment groups. Within-treatment analyses indicated that both treatments were associated with significant improvement in depression severity on self- (O3FA: t = -4.38, P < .001; placebo: t = -3.52, P = .002) and clinician (O3FA: t = -6.47, P < .001; placebo: t = -8.10, P < .001) ratings. CONCLUSIONS In adolescents with MDD, O3FA do not appear to be superior to placebo. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00962598.
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Affiliation(s)
- Vilma Gabbay
- Pediatric Mood and Anxiety Disorders Program, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029. .,Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York, USA
| | | | | | | | | | | | - Rachel G. Klein
- New York University Langone Medical Center, New York, New York
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143
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Cheung AH, Zuckerbrot RA, Jensen PS, Laraque D, Stein RE, Levitt A, Birmaher B, Campo J, Clarke G, Emslie G, Kaufman M, Kelleher KJ, Kutcher S, Malus M, Sacks D, Waslick B, Sarvet B. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management. Pediatrics 2018; 141:peds.2017-4082. [PMID: 29483201 DOI: 10.1542/peds.2017-4082] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To update clinical practice guidelines to assist primary care (PC) in the screening and assessment of depression. In this second part of the updated guidelines, we address treatment and ongoing management of adolescent depression in the PC setting. METHODS By using a combination of evidence- and consensus-based methodologies, the guidelines were updated in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) revision and iteration among the steering committee, including youth and families with lived experience. RESULTS These updated guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in PC, including (1) active monitoring of mildly depressed youth, (2) treatment with evidence-based medication and psychotherapeutic approaches in cases of moderate and/or severe depression, (3) close monitoring of side effects, (4) consultation and comanagement of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and the grade of its evidence base are summarized. CONCLUSIONS The Guidelines for Adolescent Depression in Primary Care cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist PC clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of depressed youth in PC is needed, including the usability, feasibility, and sustainability of guidelines, and determination of the extent to which the guidelines actually improve outcomes of depressed youth.
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Affiliation(s)
| | - Rachel A. Zuckerbrot
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, New York, New York
| | - Peter S. Jensen
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Danielle Laraque
- State University of New York Upstate Medical University, Syracuse, New York; and
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144
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Goodyer IM, Reynolds S, Barrett B, Byford S, Dubicka B, Hill J, Holland F, Kelvin R, Midgley N, Roberts C, Senior R, Target M, Widmer B, Wilkinson P, Fonagy P. Cognitive-behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial. Health Technol Assess 2018; 21:1-94. [PMID: 28394249 DOI: 10.3310/hta21120] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although there are effective psychological treatments for unipolar major depression in adolescents, whether or not one or more of the available therapies maintain reduced depressive symptoms 1 year after the end of treatment is not known. This is a non-trivial issue because maintaining lowered depressive symptoms below a clinical threshold level reduces the risk for diagnostic relapse into the adult years. OBJECTIVE To determine whether or not either of two specialist psychological treatments, cognitive-behavioural therapy (CBT) or short-term psychoanalytic psychotherapy (STPP), is more effective than a reference brief psychosocial intervention (BPI) in maintaining reduction of depression symptoms in the year after treatment. DESIGN Observer-blind, parallel-group, pragmatic superiority randomised controlled trial. SETTING A total of 15 outpatient NHS clinics in the UK from East Anglia, north-west England and North London. PARTICIPANTS Adolescents aged 11-17 years with Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition major depression including those with suicidality, depressive psychosis and conduct disorder. Patients were randomised using stochastic minimisation controlling for age, sex and self-reported depression sum score; 470 patients were randomised and 465 were included in the analyses. INTERVENTIONS In total, 154 adolescents received CBT, 156 received STPP and 155 received BPI. The trial lasted 86 weeks and study treatments were delivered in the first 36 weeks, with 52 weeks of follow-up. MAIN OUTCOME MEASURES Mean sum score on self-reported depressive symptoms (primary outcome) at final study assessment (nominally 86 weeks, at least 52 weeks after end of treatment). Secondary measures were change in mean sum scores on self-reported anxiety symptoms and researcher-rated Health of the Nation scales for children and adolescents measuring psychosocial function. Following baseline assessment, there were a further five planned follow-up reassessments at nominal time points of 6, 12, 52 and 86 weeks post randomisation. RESULTS There were non-inferiority effects of CBT compared with STPP [treatment effect by final follow-up = -0.578, 95% confidence interval (CI) -2.948 to 4.104; p = 0.748]. There were no superiority effects for the two specialist treatments (CBT + STPP) compared with BPI (treatment effect by final follow-up = -1.898, 95% CI -4.922 to 1.126; p = 0.219). At final assessment there was no significant difference in the mean depressive symptom score between treatment groups. There was an average 49-52% reduction in depression symptoms by the end of the study. There were no differences in total costs or quality-of-life scores between treatment groups and prescribing a selective serotonin reuptake inhibitor (SSRI) during treatment or follow-up did not differ between the therapy arms and, therefore, did not mediate the outcome. CONCLUSIONS The three psychological treatments differed markedly in theoretical and clinical approach and are associated with a similar degree of clinical improvement, cost-effectiveness and subsequent maintenance of lowered depressive symptoms. Both STPP and BPI offer an additional patient treatment choice, alongside CBT, for depressed adolescents attending specialist Child and Adolescent Mental Health Services. Further research should focus on psychological mechanisms that are associated with treatment response, the maintenance of positive effects, determinants of non-response and whether or not brief psychotherapies are of use in primary care and community settings. LIMITATIONS Neither reason for SSRI prescribing or monitoring of medication compliance was controlled for over the course of the study, and the economic results were limited by missing data. TRIAL REGISTRATION Current Controlled Trials ISRCTN83033550. FUNDING This project was funded by the National Institute for Heath Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 12. See the National Institute for Heath Research Journals Library website for further project information. Funding was also provided by the Department of Health. The funders had no role in the study design, patient recruitment, data collection, analysis or writing of the study, any aspect pertinent to the study or the decision to submit to The Lancet.
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Affiliation(s)
- Ian M Goodyer
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | | | | | - Sarah Byford
- David Goldberg Centre, King's College London, London, UK
| | - Bernadka Dubicka
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Jonathan Hill
- Child and Adolescent Psychiatry, University of Manchester, Manchester, UK.,School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Fiona Holland
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Raphael Kelvin
- Department of Psychiatry, University of Cambridge, Cambridge, UK.,Cambridge and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Nick Midgley
- Anna Freud National Centre for Children and Families, London, UK.,Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Chris Roberts
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Rob Senior
- Tavistock and Portman NHS Foundation Trust, London, UK
| | - Mary Target
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Barry Widmer
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Paul Wilkinson
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
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Brent DA, Gibbons RD, Wilkinson P, Dubicka B. Antidepressants in paediatric depression: do not look back in anger but around in awareness. BJPsych Bull 2018; 42:1-4. [PMID: 29388523 PMCID: PMC6001874 DOI: 10.1192/bjb.2017.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In this paper, we summarise and critique a network meta-analysis (NMA) of antidepressant efficacy and tolerability for paediatric depression and an accompanying editorial. Although we agree that many of the extant studies are flawed, this meta-analysis showed clear efficacy of fluoxetine in the NMA, and for sertraline and escitalopram in pairwise analyses. Consequently, these papers underestimate the benefits of antidepressants for paediatric depression, and provide support for current practice guideline, which recommends the use of an antidepressant if the patient does not respond to psychotherapy. In these circumstances, fluoxetine should be the first choice, with escitalopram and sertraline as alternatives. Declaration of interest D.A.B. receives royalties from Guilford Press, has or will receive royalties from the electronic self-rated version of the C-SSRS from eResearch Technology, Inc., is on the editorial board of UpToDate, and is a reviewer for Healthwise. R.D.G. serves as an expert witness for the US Department of Justice, Pfizer, Wyeth and GSK; and is the founder of Adaptive Testing Technologies. P.W. receives personal fees from Lundbeck and Takeda. B.D. reports a licensing agreement with Lundbeck for a psychosocial treatment manual for depression. No other disclosures were reported.
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Affiliation(s)
- David A Brent
- Western Psychiatric Institute and Clinic,University of Pittsburgh Medical Center
| | | | | | - Bernadka Dubicka
- Institute of Brain, Behaviour and Mental Health,University of Manchester
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146
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Hathaway EE, Walkup JT, Strawn JR. Antidepressant Treatment Duration in Pediatric Depressive and Anxiety Disorders: How Long is Long Enough? Curr Probl Pediatr Adolesc Health Care 2018; 48:31-39. [PMID: 29337001 PMCID: PMC5828899 DOI: 10.1016/j.cppeds.2017.12.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Anxiety and depressive disorders are common in the pediatric primary care setting, and respond to both psychotherapeutic and psychopharmacologic treatment. However, there are limited data regarding the optimal treatment duration. This article systematically reviews guidelines and clinical trial data related to antidepressant treatment duration in pediatric patients with depressive and anxiety disorders. The extant literature suggests 9-12 months of antidepressant treatment for youth with major depressive disorder. For generalized, separation and social anxiety disorders, 6-9 months of antidepressant treatment may be sufficient, though many clinicians extend treatment to 12 months based on extrapolation of data from adults with anxiety disorders. Such extended treatment periods may decrease the risk of long-term morbidity and recurrence; however, the goal of treatment is ultimately remission, rather than duration of antidepressant pharmacotherapy. Moreover, while evidence-based guidelines represent a starting point, appropriate treatment duration varies and patient-specific response, psychological factors, and timing of discontinuation must be considered for individual pediatric patients.
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Affiliation(s)
| | - John T Walkup
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jeffrey R Strawn
- Department of Psychiatry, University of Cincinnati College of Medicine, Box 0559, Cincinnati, OH 45267-0559.
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147
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Dickerson JF, Feeny DH, Clarke GN, MacMillan AL, Lynch FL. Evidence on the longitudinal construct validity of major generic and utility measures of health-related quality of life in teens with depression. Qual Life Res 2018; 27:447-454. [PMID: 29149441 DOI: 10.1007/s11136-017-1728-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To examine the longitudinal construct validity in the assessment of changes in depressive symptoms of widely used utility and generic HRQL instruments in teens. METHODS 392 teens enrolled in the study and completed HRQL and diagnostic measures as part of the baseline interview. HRQL measures included EuroQol (EQ-5D-3L), Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3), Quality of Well-Being Scale (QWB), Pediatric Quality of Life Inventory (PEDS-QL), RAND-36 (SF-6D), and Quality of Life in Depression Scale (QLDS). Youth completed follow-up interviews 12 weeks after baseline. Sixteen youth (4.1%) were lost to follow-up. We examined correlations between changes in HRQL instruments and the Children's Depression Rating Scale-Revised (CDRS-R) and assessed clinically meaningful change in multi-attribute utility HRQL measures using mean change (MC) and standardized response mean (SRM) among youth showing at least moderate (20%) improvement in depression symptomology. RESULTS Spearman's correlation coefficients demonstrated moderate correlation between changes in CDRS-R and the HUI2 (r = 0.38), HUI3 (r = 0.42), EQ-5D-3L (r = 0.36), SF-6D (r = 0.39), and PEDS-QL (r = 0.39) and strong correlation between changes in CDRS-R and QWB (r = 0.52) and QLDS (r = - 0.71). Effect size results are also reported. Among multi-attribute utility measures, all showed clinically meaningful improvements in the sample of youth with depression improvement (HUI2, MC = 0.20, SRM = 0.97; HUI3, MC = 0.32, SRM = 1.17; EQ-5D-3L, MC = 0.08, SRM = 0.51; QWB, MC = 0.11, SRM = 0.86; and SF-6D, MC = 0.12, SRM = 1.02). CONCLUSIONS Findings support the longitudinal construct validity of included HRQL instruments for the assessment of change in depression outcomes in teens. Results of this study can help inform researchers about viable instruments to include in economic evaluations for this population.
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Affiliation(s)
- John F Dickerson
- Center for Health Research - Kaiser Permanente, 3800 N. Interstate Ave., Portland, OR, 97227, USA.
| | - David H Feeny
- Department of Economics, McMaster University, Hamilton, ON, Canada
- Health Utilities Incorporated, Dundas, ON, Canada
| | - Gregory N Clarke
- Center for Health Research - Kaiser Permanente, 3800 N. Interstate Ave., Portland, OR, 97227, USA
| | - Alex L MacMillan
- ThinkShout, Inc, 433 NW 4th Ave, Suite 100, Portland, OR, 97209, USA
| | - Frances L Lynch
- Center for Health Research - Kaiser Permanente, 3800 N. Interstate Ave., Portland, OR, 97227, USA
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148
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Garber J, Weersing VR, Hollon SD, Porta G, Clarke GN, Dickerson JF, Beardslee WR, Lynch FL, Gladstone TG, Shamseddeen W, Brent DA. Prevention of Depression in At-Risk Adolescents: Moderators of Long-term Response. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2018; 19:6-15. [PMID: 26830893 PMCID: PMC4969230 DOI: 10.1007/s11121-015-0626-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In a randomized controlled trial, we found that a cognitive behavioral program (CBP) was significantly more effective than usual care (UC) in preventing the onset of depressive episodes, although not everyone benefitted from the CBP intervention. The present paper explored this heterogeneity of response. Participants were 316 adolescents (M age = 14.8, SD = 1.4) at risk for depression due to having had a prior depressive episode or having current subsyndromal depressive symptoms and having a parent with a history of depression. Using a recursive partitioning approach to baseline characteristics, we (Weersing et al. 2016) previously had identified distinct risk clusters within conditions that predicted depressive episodes through the end of the continuation phase (month 9). The present study used the same risk clusters that had been derived in the CBP group through month 9 to reclassify the UC group and then to examine group differences in depression through month 33. We found that in this overall very high-risk sample, the CBP program was superior to UC among youth in the low-risk cluster (n = 33), characterized by higher functioning, lower anxiety, and parents not depressed at baseline, but not in the middle (n = 95) and high-risk (n = 25) clusters. Across conditions, significantly more depression-free days were found for youth in the low-risk cluster (M = 951.9, SD = 138.8) as compared to youth in the high-risk cluster (M = 800.5, SD = 226.7). Identification of moderators, based on purely prognostic indices, allows for more efficient use of resources and suggests possible prevention targets so as to increase the power of the intervention.
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Affiliation(s)
- J Garber
- Department of Psychology and Human Development, Vanderbilt University, 552 Peabody, 230 Appleton Pl, Nashville, TN, USA.
| | - V R Weersing
- Joint Doctoral Program in Clinical Psychiatry, San Diego State University, San Diego, CA, USA
- University of California, San Diego, CA, USA
| | - S D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - G Porta
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - G N Clarke
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - J F Dickerson
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - W R Beardslee
- Department of Psychiatry, Boston Children's Hospital, Boston, MA, USA
| | - F L Lynch
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - T G Gladstone
- Wellesley Centers for Women, Wellesley College, Wellesley, MA, USA
| | | | - D A Brent
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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149
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Patel DR, Feucht C, Brown K, Ramsay J. Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners. Transl Pediatr 2018; 7:23-35. [PMID: 29441280 PMCID: PMC5803020 DOI: 10.21037/tp.2017.08.05] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Anxiety disorders are common in children and adolescents with reported prevalence rates between 10% and 30%. A combined approach to treatment has been found to be the most effective for optimal outcomes and is typically comprised of psychotherapy (especially exposure-based cognitive behavior therapy), family and patient education, and use of medication if indicated. In children and adolescents who might benefit from use of medications, selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice. The safety and efficacy of medications other than SSRIs in the treatment of children and adolescents with anxiety disorders are not fully established. Most children and adolescents respond well to treatment with long lasting resolution of symptoms, although, recurrence of the same, or development of a different type of anxiety disorder, is not uncommon. In most children and adolescents, anxiety disorders tend to persist into adulthood requiring long-term treatment planning. This paper reviews the pharmacological agents used in the treatment of anxiety disorders in children and adolescents.
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Affiliation(s)
- Dilip R Patel
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
| | - Cynthia Feucht
- Cynthia Feucht, Adjunct Faculty, Ferris State University, College of Pharmacy, Clinical Pharmacy Specialist, Borgess Internal Medicine, Portage, MI, USA
| | - Kelly Brown
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
| | - Jessica Ramsay
- Department of Pediatric and Adolescent Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
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150
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Bee P, Pedley R, Rithalia A, Richardson G, Pryjmachuk S, Kirk S, Bower P. Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BackgroundSelf-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.ObjectivesTo determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.DesignSystematic review with meta-analysis.PopulationChildren and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).InterventionSelf-care support in health, social care, educational or community settings.ComparatorUsual care.OutcomesGeneric/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.DesignRandomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.Data sourcesMEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.MethodsWe conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).ResultsNinety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.LimitationsIdentification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.ConclusionsSelf-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.Future workResearch is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.Study registrationThis study is registered as PROSPERO CRD42014015452.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Penny Bee
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Rebecca Pedley
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Amber Rithalia
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Steven Pryjmachuk
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Susan Kirk
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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