Treat depressed teens with medication &lt;i&gt;and&lt;/i&gt; psychotherapy

,; Smith, Sandy; ,

PURLs

Treat depressed teens with medication and psychotherapy

J Fam Pract. 2008 November;57(11):735-739, 739a

PDF Download

References

1. Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA. 2008;299:901-913.

2. March JS, Silva S, Petrycki S, et al. The Treatment for Adolescents With Depression Study (TADS): long-term effectiveness and safety outcomes. Arch Gen Psychiatry. 2007;64:1132-1143.

3. March J, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292:807-820.

4. Kessler RC, Walters EE. Epidemiology of DSM-IIIR major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depress Anxiety. 1998;7:3-14.

5. Rushton JL, Clark SJ, Freed GL. Pediatrician and family physician prescription of selective serotonin reuptake inhibitors. Pediatrics. 2000;105:E82.

6. Hankin BL. Adolescent depression: description, causes, and interventions. Epilepsy Behav. 2006;8:102-114.

7. Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE . Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120:e1313-e1326.

8. Birmaher B , Brent DA, Benson RS. Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 1998;37:1234-1238.

9. Yates P, Kramer T, Garralda E . Depressive symptoms amongst adolescent primary care attenders. Levels and associations. Soc Psychiatry Psychiatr Epidemiol. 2004;39:588-594.

10. Rushton JL, Forcier M , Schectman RM . Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health. J Am Acad Child Adolesc Psychiatry. 2002;41:199-205.

11. Johnson JG, Harris ES, Spitzer RL , Williams JB. The patient health questionnaire for adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolesc Health. 2002;30:196-204.

12. Compton SN, March JS, Brent D, Albano AM, Weersing R , Curry J. Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. J Am Acad Child Adolesc Psychiatry. 2004;43:930-959.

13. Asarnow JR, Jaycox L H, Anderson M . Depression among youth in primary care models for delivering mental health services. Child Adolesc Psychiatr Clin N Am. 2002;11:477-497, viii.

14. Wisdom JP, Clarke GN, Green CA. What teens want: barriers to seeking care for depression. Adm Policy Ment Health. 2006;33:133-145.

15. Zuckerbrot R A, Cheung AH, Jensen PS, Stein RE , Laraque D. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007;120:e1299-e1312.

16. Van Voorhees B W, Fogel J, Houston TK, Cooper LA, Wang NY, Ford DE. Beliefs and attitudes associated with the intention to not accept the diagnosis of depression among young adults. Ann Fam Med. 2005;3:38-46.

17. Clever SL, Ford DE, Rubenstein LV , et al. Primary care patients’ involvement in decision-making is associated with improvement in depression. Med Care. 2006;44:398-405.

18. Lacasse JR. Consumer advertising of psychiatric medications biases the public against nonpharmacological treatment. Ethical Hum Psychol Psychiatry. 2005;7:175-179.

19. Van Voorhees B W, Cooper L A, Rost KM, et al. Primary care patients with depression are less accepting of treatment than those seen by mental health specialists. J Gen Intern Med. 2003;18:991-1000.

20. Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ. 2004;328:265.

21. Anderson L , Lewis G, Araya R, et al. Self-help books for depression: how can practitioners and patients make the right choice? Br J Gen Pract. 2005;55:387-392.

22. Van Voorhees B W, Vanderploegbooth K, Fogel J, et al. Integrative Internet-based depression prevention for adolescents: a randomized clinical trial in primary care for vulnerability and protective factors. J Can Acad Child Adoles Psychiatry. In press.

WHAT'S NEW?

An alternative that speeds recovery

These 2 studies confirm the value of CBT in treating moderate to severe major depression in combination with antidepressant therapy. TADS provides evidence of both a faster recovery trajectory and lower likelihood of suicidal events with combined treatment. While TORDIA does not demonstrate a quicker recovery in terms of depressed mood or a lower rate of suicidal events, it suggests that for adolescents who do not respond to antidepressants, a referral to CBT will be more effective than a switch to a different drug.

CAVEATS

Approach was not tested with mild depression Telling teens that "brain changes" cause depression may alleviate the stigma and self-blame.

Most adolescents who report depressive symptoms to primary care physicians either do not meet the full criteria for major depression or fall into the mild major depression range.^9-11 Both of these studies enrolled only those with moderate to severe MDD.

There is evidence, however, that such an approach may not be necessary for teens with milder depression. Many earlier studies of psychotherapy alone vs control (wait list or observation) for patients with sub-threshold depressive disorders or mild major depression demonstrated that psychotherapy is effective in treating these less severe depressive states.^7,12 GLAD-PC recommends a 4- to 8-week trial of active monitoring for patients with mild MDD before initiating psychotherapy or medication.²

CHALLENGES TO IMPLEMENTATION

Patient perceptions, stigma

There are 3 major barriers to implementation: patient/parent resistance to psychotherapy, limited access to mental health specialists (lack of supply and insurance coverage limitations), and few quality standards for evidence-based psychotherapeutic approaches in community practice settings.^13-15 Many adolescents have a negative view of therapy and feel stigmatized by a referral to a psychotherapist. They may also have a well-developed rationale as to why such treatment would not work for them.¹⁶

Physicians can help teens overcome these negative perceptions by giving them an opportunity to discuss their concerns—and by clarifying any misconceptions.¹⁷ The idea that “brain changes” cause depression has become popular in recent years,¹⁸ and may provide some relief to those who are troubled by the notion that they are somehow to blame for their depression.¹⁹ Presenting both antidepressant medication and psychotherapy as interventions that “change the way the brain manages mood” may be helpful in alleviating self-blame.

Consider nontraditional approaches

In areas with limited access to mental health specialists, nontraditional approaches may be needed. One such approach is to help patients arrange an initial interview with a psychotherapist, followed by telephone counseling sessions. For patients 18 years or older, MoodGym (http://moodgym.anu.edu.au/welcome) is also an option. This free Internet site incorporates features of standardized CBT and interpersonal therapy, and has demonstrated efficacy in RCTs of adults.²⁰ For those between the Want to learn more about CBT? Check out the web table at the bottom of this article. ages of 14 and 21, CATCH-IT (http://catchit-public.bsd.uchicago.edu)²¹ is another Internet option. The site, which can be accessed by physicians and the general public, focuses on building competencies to reduce current and future depressive symptoms.

In addition, recommend self-help books. While there have been no studies of their value to adolescents, the book with the greatest evidence of efficacy in adults is “Feeling Good: The New Mood Therapy,” by David D. Burns.²²

For your part... Before making referrals to mental health specialists, ask therapists whether they incorporate, and have been trained in, cognitive behavioral therapy. In addition, you can remain involved by asking the psychotherapist for a written treatment plan and by encouraging adolescents (and their families) to fully adhere to it.

ACKNOWLEDGEMENTS

The Purls Surveillance System is supported in part by Grant Number ul1rr024999 from the National Center For research resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For research resources or the National Institutes of Health.
Benjamin Van Voorhees is supported by a career development award from the National Institutes of Mental Health (NImHK-08mH072918-01A2).