The efficacy of antidepressants on overall well-being and self-reported depression symptom severity in youth: a meta-analysis

Major challenges in youth psychopathology: treatment-resistant depression. A narrative review

Major depressive disorder (MDD) represents a major health issue in adolescents and young adults, leading to high levels of disability and profoundly impacting overall functioning. The clinical presentation of MDD in this vulnerable age group may slightly differ from what can be observed in adult populations, and psychopharmacological strategies do not always lead to optimal response. Resistance to antidepressant treatment has a prevalence estimated around 40% in youths suffering from MDD and is associated with higher comorbidity rates and suicidality. Several factors, encompassing biological, environmental, and clinical features, may contribute to the emergence of treatment-resistant depression (TRD) in adolescents and young adults. Furthermore, TRD may underpin the presence of an unrecognized bipolar diathesis, increasing the overall complexity of the clinical picture and posing major differential diagnosis challenges in the clinical practice. After summarizing current evidence on epidemiological and clinical correlates of TRD in adolescents and young adults, the present review also provides an overview of possible treatment strategies, including novel fast-acting antidepressants. Despite these pharmacological agents are promising in this population, their usage is expected to rely on risk-benefit ratio and to be considered in the context of integrated models of care.

The Influence of Long Working Hours, Occupational Stress, and Well-Being on Depression Among Couriers in Zhejiang, China

Objective:

This study aimed to examine the association between long working hours, occupational stress, depression, and well-being, and to explore the intermediary effect of occupational stress and well-being between working hours and depression among couriers in Zhejiang, China.

Methods:

The study used a cluster random sampling method to select 1,200 couriers from mainstream express companies in Zhejiang, China. The data were collected and analyzed using the Core Occupational Stress Scale (COSS) to measure occupational stress, the Patient Health Questionnaire-9 (PHQ-9) scale to evaluate depression, and the World Health Organization five-item Well-Being Index (WHO-5) scale to assess well-being. Structural equation modeling (SEM) was used to test the hypothesized relationship among the variables.

Results:

The phenomenon of long working hours (75.1%) was quite common among couriers in Zhejiang, China. Working hours had a direct positive effect on depression (β = 0.008, p < 0.001) and on occupational stress (β = 0.009, p < 0.001), and working hours had a negative effect on well-being (β = −0.013, p < 0.001). Occupational stress had a direct positive effect on depression (β = 0.272, p < 0.001), but well-being had no significant direct effect on depression. Working hours had an indirect effect on depression through the mediating effect of occupational stress while the mediating effect of well-being was not found.

Conclusion:

Long working hours is associated with occupational stress, well-being, and depression. Our results confirmed that working hours, occupational stress, and well-being were strong predicators of depression. Working hours had a significant indirect effect on depression via occupational stress. The result of this study showed that decreasing working hours and reducing occupational stress would be effective for couriers to prevent depression. However, more studies are needed to verify the relationship between working hours and depression.

The comparative effectiveness of antidepressants for youths with major depressive disorder: a nationwide population-based study in Taiwan

Background:

Guidelines recommend fluoxetine as a first-line medication for youths diagnosed with major depressive disorder (MDD). However, little is known about the long-term effectiveness of different antidepressants in juveniles in the real world. This study aimed to compare the effectiveness of antidepressants in youths with MDD.

Methods:

Youths (<20 years old) with a diagnosis of MDD who were new users of antidepressants were selected from a nationwide population-based cohort in Taiwan between 1997 and 2013. We divided a total of 16,981 users (39.9% male; mean age: 16.6 years) into 10 different antidepressant groups (fluoxetine, sertraline, paroxetine, venlafaxine, citalopram, escitalopram, bupropion, fluvoxamine, mirtazapine and moclobemide). Regarding treatment outcomes (hospitalisation and medication discontinuation), Cox proportional hazards regression models were applied to estimate the hazards of such outcomes.

Results:

Compared with the youths treated with fluoxetine, the bupropion-treated group demonstrated lower rates of hospitalisation and discontinuation. Mirtazapine-treated group demonstrated a higher hospitalisation risk mainly when administered for single depressive episodes. Furthermore, patients treated with sertraline and fluvoxamine had higher discontinuation rates. Among the younger teenage subgroups (< 16 years), significantly higher rates of discontinuation were observed in those treated with sertraline, escitalopram and fluvoxamine. Among the older teenage subgroups (⩾ 16 years), bupropion was superior to fluoxetine in preventing hospitalisation and discontinuation.

Conclusion:

We concluded that bupropion might surpass fluoxetine with regard to hospitalisation prevention and drug therapy maintenance among youths with MDD, while mirtazapine users demonstrated a higher hospitalisation risk. Our findings might serve as a reference for clinicians in future studies.

The trial support program for empowerment of parents of children with ADHD

This study was conducted to investigate the effectiveness of the Family Empowerment Program, which aims to reduce the stress level of parents with a child diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and to increase their quality of life. In the research, experimental design with pre-test and post-test control group was used. The research group included volunteer parents with children diagnosed with ADHD who are currently enrolled at one of the preschool or primary school institutions of the Ministry of National Education in Turkish Republic of Northern Cyprus. The study was carried out with 65 participants who were divided into two groups. Namely, the experiment group (n = 33) and the control group (N = 32). Random assignment method was used in the distribution of parents to groups. Perceived Stress Level and Beach Center Family Life Quality Scale were applied to parents. In the study, the period of each session was determined as 60 minutes and consisted of 17 sessions (three sessions per a week) at a support education room of a private psychotherapy center. The impact size at the stress level for the experimental group was determined as 12.2%. The results of the study reveal that the psycho-educational empowerment program is effective.

Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: an umbrella review

Top-tier evidence on the safety/tolerability of 80 medications in children/adolescents with mental disorders has recently been reviewed in this jour-nal. To guide clinical practice, such data must be combined with evidence on efficacy and acceptability. Besides medications, psychosocial inter-ventions and brain stimulation techniques are treatment options for children/adolescents with mental disorders. For this umbrella review, we systematically searched network meta-analyses (NMAs) and meta-analyses (MAs) of randomized controlled trials (RCTs) evaluating 48 medications, 20 psychosocial interventions, and four brain stimulation techniques in children/adolescents with 52 different mental disorders or groups of mental disorders, reporting on 20 different efficacy/acceptability outcomes. Co-primary outcomes were disease-specific symptom reduction and all-cause discontinuation ("acceptability"). We included 14 NMAs and 90 MAs, reporting on 15 mental disorders or groups of mental disorders. Overall, 21 medications outperformed placebo regarding the co-primary outcomes, and three psychosocial interventions did so (while seven outperformed waiting list/no treatment). Based on the meta-analytic evidence, the most convincing efficacy profile emerged for amphetamines, methylphenidate and, to a smaller extent, behavioral therapy in attention-deficit/hyperactivity disorder; aripiprazole, risperidone and several psychosocial interventions in autism; risperidone and behavioral interventions in disruptive behavior disorders; several antipsychotics in schizophrenia spectrum disorders; fluoxetine, the combination of fluoxetine and cognitive behavioral therapy (CBT), and interpersonal therapy in depression; aripiprazole in mania; fluoxetine and group CBT in anxiety disorders; fluoxetine/selective serotonin reuptake inhibitors, CBT, and behavioral therapy with exposure and response prevention in obsessive-compulsive disorder; CBT in post-traumatic stress disorder; imipramine and alarm behavioral intervention in enuresis; behavioral therapy in encopresis; and family therapy in anorexia nervosa. Results from this umbrella review of interventions for mental disorders in children/adolescents provide evidence-based information for clinical decision making.

Good, better, best: clinical scenarios for the use of L-methylfolate in patients with MDD

Depression is among the most prevalent mental disorders worldwide, and a substantial proportion of patients do not respond adequately to standard antidepressants. Our understanding of the pathophysiology of depression is no longer limited to the chemical imbalance of neurotransmitters, but also involves the interplay of proinflammatory modulators in the central nervous system, as well as folate metabolism. Additional factors such as stress and metabolic disorders also may contribute. Multiple inflammatory, metabolic, and genetic markers have been identified and may provide critical information to help clinicians individualize treatments for patients to achieve optimal outcomes. Recent advancements in research have clarified underlying causes of depression and have led to possible new avenues for adjunctive treatment. Among these is L-methylfolate, a medical food that is thought to enhance synthesis of monoamines (serotonin, norepinephrine, and dopamine), suppress inflammation, and promote neural health. Clinical studies that assessed supplemental use of L-methylfolate in patients with usual care-resistant depression found that it resulted in improved outcomes. Patients with selective serotonin reuptake inhibitor-resistant depression, and particularly subgroups with biomarkers of inflammation or metabolic disorders or folate metabolism-related genetic polymorphisms (or ≥2 of these factors), had the best responses. Considering this, the goals of this review are to 1) highlight recent advances in the pathophysiology of major depressive disorder as it pertains to folate and associated biomarkers and 2) establish the profiles of patients with depression who could benefit most from supplemental use of L-methylfolate.

Duty to Warn: Antidepressant Black Box Suicidality Warning Is Empirically Justified

The United States Food and Drug Administration issued a Black Box warning in October 2004 after placebo-controlled trials of antidepressant medications found an increased risk of suicidal thoughts and behaviors among children and adolescents taking antidepressant medications relative to placebo. Subsequently, some researchers have concluded that the Black Box warning caused severe unintended consequences; specifically, they have argued that the warning led to reduced use of antidepressants among youth, which led to more suicides. In this paper, we critically examine research regarding the Black Box warning's alleged deleterious consequences. One study claimed that controlled trials did not actually find an increased risk of suicidality among youth taking fluoxetine relative to those taking placebo, but its measure of suicidality is likely invalid. We found that ecological time series studies claiming that decreasing antidepressant prescriptions are linked to higher rates of suicide attempts or actual suicides among youth were methodologically weak. These studies exhibited shortcomings including: selective use of time points, use of only a short-term time series, lack of performing statistical analysis, not examining level of severity/impairment among participants, inability to control confounding variables, and/or use of questionable measures of suicide attempts. Further, while some time-series studies claim that increased antidepressant prescriptions are related to fewer youth suicides, more recent data suggests that increasing antidepressant prescriptions are related to more youth suicide attempts and more completed suicides among American children and adolescents. We also note that case-control studies show increased risk of suicide attempts and suicide among youth taking antidepressants, even after controlling for some relevant confounds. As clinical trials have the greatest ability to control relevant confounds, it is important to remember such trials demonstrated increased risk of suicidality adverse events among youth taking antidepressants. The Black Box warning is firmly rooted in solid data whereas attempts to claim the warning has caused harm are based on quite weak evidence.

Editorial: Room for Improvement in the Treatment of Youth Depression

Psychotherapy has been studied for decades and is often used to treat youths with depression. How well does it work? Eckshtain et al.¹ answered this question with a thoughtful, complex meta-analysis of 53 psychotherapy trials. Psychotherapy was significantly superior relative to control groups. More revealingly, treatment effects were small to moderate (g = .49) compared with no treatment, small (g = .29) compared with a broad range of usual care interventions, and middling and statistically insignificant (g = .16) relative to placebo interventions (nearly all placebo psychotherapies merely controlling for therapist attention; only one study used pill placebo). I describe these findings in the context of research on both psychotherapy and antidepressant medications. The current meta-analysis and a wider body of research provide guidance for both clinicians and researchers.

Psychotropic medications for highly vulnerable children

INTRODUCTION

At least 20% of children in the U.S. are highly vulnerable because they lack healthcare and protection. Several factors produce vulnerability: trauma, disruptions of parenting, poverty, involvement in the juvenile justice and/or child welfare systems, residence in restrictive settings, and problems related to developmental disabilities. These children receive psychotropic medications at high rates, raising numerous concerns.

AREAS COVERED

The authors begin this review with a description of the population of highly vulnerable children. They then follow this with a review of the effectiveness and side effects of psychotropic medications for their most common diagnoses, using the highest-quality systematic reviews identified by multiple database searches.

EXPERT OPINION

Highly vulnerable children receive numerous psychotropic medications with high rates of polypharmacy, off-label use, and long-term use, typically in the absence of adjunctive psychosocial interventions. The current evidence contravenes these trends. Future studies of psychotropic medications in vulnerable children should include long-term effectiveness trials and polypharmacy in conjunction with evidence-based, family-centered, psychosocial treatments.

Moderators in psychotherapy meta-analysis

Psychotherapy meta-analyses sometimes generate heterogeneous results, partially due to key methodological characteristics which vary between studies (e.g., psychotherapy conditions are contrasted with structurally different control conditions). Examining these potential moderator variables can help explain heterogeneous results within and between psychotherapy meta-analyses. The present manuscript provides an overview of moderators that are highly relevant to test the generalizability of effects across psychotherapy trials. These moderators mainly fall into one of the following groups: (a) structural equivalence of interventions, (b) preferences/allegiances, (c) therapist effects, and (d) sample representativeness. Individual moderators include: Bona fide psychotherapy, proximity to psychological interventions, psychotherapy orientation, pre-training of therapists, supervision, caseload of therapists, dosage, homework, patient preferences, researcher and therapist allegiance, therapist effects in nested designs, aspects of sample representativeness, multiple outcomes, and time of assessment. Our analysis of 15 psychotherapy meta-analyses published in 2016 suggests that the structural equivalence of psychotherapeutic conditions, patient and therapist preferences/allegiances, therapist effects and nested data structures as well as sample representativeness were often neglected and little-discussed as potential moderators. The manuscript describes further conceptual and methodological challenges when conducting moderator analyses such as the categorization of psychological treatments and the importance of interrater coding. We encourage meta-analysts to consider moderators which have previously shown utility in explaining heterogeneous results in the psychotherapy literature. Clinical or methodological significance of this article: Relevant moderator variables help explain heterogeneous results in psychotherapy meta-analyses. Though these variables are often overlooked, they should be regularly incorporated in meta-analyses.

Effect of treatments for depression on quality of life: a meta-analysis

Cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are the two first-line treatments for depression, but little is known about their effects on quality of life (QOL). A meta-analysis was conducted to examine changes in QOL in adults with major depressive disorder who received CBT (24 studies examining 1969 patients) or SSRI treatment (13 studies examining 4286 patients) for their depression. Moderate improvements in QOL from pre to post-treatment were observed in both CBT (Hedges' g = .63) and SSRI (Hedges' g = .79) treatments. The effect size remained stable over the course of the follow-up period for CBT. No data were available to examine follow-ups in the SSRI group. QOL effect sizes decreased linearly with publication year, and greater improvements in depression were significantly associated with greater improvements in QOL for CBT, but not for SSRIs. CBT and SSRIs for depression were both associated with moderate improvements in QOL, but are possibly caused by different mechanisms.

Pharmacological treatment of children and adolescents with depression

INTRODUCTION

Despite an increasing number of studies, there is debate whether antidepressants have a favorable benefit/risk balance in depressed youth. Areas covered: A systematic search identified 23 systematic reviews and meta-analyses published between 2010-2016. More than 30 controlled clinical trials were conducted in adolescents, but only a few in pre-pubertal patients. About one-third of the trials were severely statistically underpowered. Most studies failed to detect differences from placebo, but a few found fluoxetine effective. Although no suicide occurred in these studies, antidepressants increased suicidality risk (including suicidal ideation and behavior) versus placebo (OR = 2.39). Only two placebo-controlled trials with acceptable statistical power were publicly funded: both showed efficacy of fluoxetine, and one found a higher incidence of suicidality (OR = 3.7, 95% C.I. 1.00-13.7). Expert opinion: In youth, antidepressants have, on average, a small therapeutic effect. The high placebo response is exacerbated by the large number of sites in many industry-funded studies. There is evidence that fluoxetine leads to greater and faster improvement than placebo or psychotherapy in adolescents. Considering both the high response to non-specific interventions and safety concerns, antidepressants should be used cautiously in youth, and limited to patients with moderate-to-severe depression for whom psychosocial interventions are either ineffective or not feasible.

A review of nutrient treatments for paediatric depression

Paediatric depression is estimated to affect 15-20% of youths prior to adulthood and is associated with significant social, educational and physical impairment. Current treatments comprise moderately efficacious psychological therapies and pharmaceutical antidepressants. However, nutritional therapies are also available and are regularly sought by people with depressive illnesses and parents of depressed youths. In this narrative review, studies examining the antidepressant effects of individual nutritional supplements in child and adolescent populations are appraised. Epidemiological studies examining the relationship between nutritional status and paediatric depression, or depressive symptoms are also reviewed. Nutrients covered in this article include: omega-3 polyunsaturated fatty acids, s-adenosylmethionine, vitamin C, vitamin D, zinc, iron and B-vitamins. Although several of these nutrients present as promising treatments for paediatric depression, there is a lack of high-quality studies examining the antidepressant effects of all the aforementioned ingredients. Before nutritional treatments are accepted as validated treatments for paediatric depression, further high-quality studies are required.