Study finds that if first antidepressant doesn't work, try a second and add psychotherapy
TUESDAY, Feb. 26 (HealthDay News) -- If a depressed teen doesn't respond to treatment with commonly prescribed antidepressants the first time around, new research suggests there's still hope.
Switching medications and adding behavioral talk therapy turned out to be the most effective alternative, although just switching medications also helped many individuals.
"On average, these kids were ill for two years and no matter which treatment they got, at least 40 percent responded within 12 weeks," said study author Dr. David Brent, a professor of psychiatry at the University of Pittsburgh School of Medicine. "I really think the take-home message to families is if you don't respond to the first treatment, don't give up."
The study appears in the Feb. 27 issue of the Journal of the American Medical Association.
The issue of whether depressed or troubled children should even take antidepressants has been at the center of an intense public debate in recent years.
Some research has turned up evidence that kids on antidepressants have a higher rate of suicide ideation, meaning suicidal thoughts and behavior.
Heeding this data, the U.S. Food and Drug Administration in 2004 asked manufacturers of antidepressants to add a black-box warning to their labels warning about the increased suicide risk.
Recent research, however, has found that the benefits of antidepressants outweigh the risks for children and teens under the age of 19.
About 60 percent of adolescents with depression respond to treatment with antidepressants known as selective serotonin reuptake inhibitors (SSRIs).
Guidelines recommend prescribing SSRI medications, psychotherapy or both as a first-line treatment for this younger population. (The only SSRI approved by the FDA for use in pediatric patients is Prozac, but others are prescribed on an off-label basis).
Unfortunately, 40 percent do not respond to the first therapy they try, and there's little guidance on what to do next.
"There's just not that much research in kids, period," said Dr. Jane Ripperger-Suhler, an assistant professor of psychiatry and behavioral science at Texas A&M Health Science Center College of Medicine and a psychiatrist with Scott & White Mental Health Center in Temple.
For this latest study, the researchers chose 334 patients aged 12 to 18 years, all of whom had major depressive disorder and had not responded to two months of SSRI treatment. They were randomly selected to receive one of four treatment possibilities for 12 weeks: a second, different SSRI; a different SSRI plus cognitive behavioral therapy; Effexor (a serotonin-norepinephrine reuptake inhibitor, or SNRI); or Effexor plus cognitive behavioral therapy.
While the drugs were taken for 12 weeks; therapy lasted nine sessions.
There was a 54.8 percent response rate among those teens who switched to talk therapy plus either medication, compared to 40.5 percent for a medication switch alone.
There was no difference in response rates between Effexor and a second SSRI. However, there was a greater increase in blood pressure and pulse and more frequent skin problems with Effexor than the other drugs.
Ripperger-Suhler said that every time she puts a teen on an antidepressant, she refers them for therapy anyway. The results of this trial might prompt primary-care doctors, who are more apt to write a prescription and do nothing else, to also recommend therapy, she said.
One caveat, however, is that there are few really good cognitive behavioral therapists out there, nor is there any way to distinguish clearly among them, Ripperger-Suhler stated. "To do cognitive behavioral therapy effectively you really need someone who is well-trained and there aren't very many," she said.
But other types of talk therapy might also be effective, she added.
Visit the U.S. National Institute of Mental Health for more on adolescent depression.
SOURCES: David Brent, M.D., professor, psychiatry, University of Pittsburgh School of Medicine; Jane Ripperger-Suhler, M.D., assistant professor, psychiatry and behavioral science, Texas A&M Health Science Center College of Medicine, and psychiatrist, Scott & White Mental Health Center, Temple; Feb. 27, 2007, Journal of the American Medical Association
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