Efficacy of tricyclic drugs in treating child and adolescent depression: a meta-analysis

Selective serotonin reuptake inhibitor and venlafaxine use in children and adolescents with major depressive disorder: a systematic review of published randomized controlled trials

OBJECTIVE

This review critiques published randomized placebo-controlled trials pertaining to the efficacy and safety of selective serotonin reuptake inhibitors (SSRIs) and venlafaxine in the treatment of major depressive disorder in children and adolescents.

METHOD

Medline was searched for articles meeting defined inclusion criteria. The following key terms were used: depressive disorders, antidepressive agents, fluoxetine, paroxetine, sertraline, citalopram, fluvoxamine, venlafaxine, child, and adolescent.

RESULTS

Six articles met inclusion criteria. Only 2 studies claim efficacy by significant results in primary outcomes; both have since been contested in further analysis. Not one study adequately examines safety, particularly with respect to whether a link exists between antidepressant use and induction of suicidal ideation or attempts.

CONCLUSION

Published studies on SSRI or venlafaxine use in children and adolescents are inconclusive with respect to safety and efficacy, owing to inappropriate claims of efficacy, lack of improvement in global functioning scores, nonstandardized data collection regarding adverse effects, exclusion of suicidal subjects in the recruitment process, grouping of children and adolescents together, small sample sizes, conflict of interest posed by pharmaceutical company sponsorship, and publishing bias. Future investigators should consider these factors when developing study designs.

Leitlinien zur Diagnostik und Psychotherapie von depressiven Störungen im Kindes- und Jugendalter: Ein evidenzbasierter Diskussionsvorschlag

Zusammenfassung. Ein Entwurf evidenzbasierter Leitlinien zur Diagnostik und Psychotherapie von depressiven Störungen im Kindes- und Jugendalter wird vorgestellt. Für die Diagnosestellung depressiver Störungen im Kindes- und Jugendalter müssen die gleichen diagnostischen Kriterien nach ICD-10 erfüllt sein wie für Erwachsene. Allerdings kann das klinische Bild einer Depression in verschiedenen Altersgruppen deutlich variieren. Depressive Störungen sind vor allem im Jugendalter häufig, chronische Verläufe und Rückfälle treten auf und sie gehen oft mit komorbiden Störungen wie Angststörungen, Störungen des Sozialverhaltens und Störungen durch Substanzgebrauch einher. Wirksame Interventionsansätze zur Prävention depressiver Störungen und zur Akutbehandlung bei leichten und mittelschweren depressiven Störungen stehen zur Verfügung. Die psychotherapeutischen Interventionen der Wahl stellen derzeit kognitiv-verhaltenstherapeutische Ansätze (KVT) und die interpersonale Therapie (IPT) dar. Die Antidepressiva der Wahl sind derzeit selektive Serotoninwiederaufnahmehemmer (SSRI). Weitere Studien, vor allem hinsichtlich Rückfallprophylaxe und der Evaluation der Wirksamkeit einer Kombinationsbehandlung von Psychotherapie mit antidepressiver Medikation stehen noch aus.

Pediatric psychopharmacology for the major psychiatric disorders found in the residential treatment setting

Intensive measures of rehabilitation are effective for treating the chronic course of the major pediatric psychiatric diagnoses. The treatment of these dis-orders in a residential treatment setting involves a coordinated team approach with components individually tailored to meet patient needs. Whereas milieu,group, and individual psychotherapy are important aspects of treatment, along with educational programming and behavior management, psychopharmacology currently plays an integral role in the treatment of children and adolescents with chronic mental illness in the residential treatment setting. Pharmacologic interventions in chronic psychiatric illnesses have decreased suffering and improved the quality of life for countless children and adolescents. In many cases, we still do not know what kind of pharmacologic treatment is best for each individual patient. Despite the progress of the past decade, further clinical research is needed with well-designed clinical trials for chronic psychiatric illnesses in children and adolescents.

Quality assessment of meta-analyses of RCTs of pharmacotherapy in major depressive disorder

BACKGROUND

Meta-analyses (MAs) of randomized controlled trials (RCTs) have the potential to provide the highest level of evidence, but the quality of published MAs has not been systematically assessed. Therefore, we determined reliability was significant (kappa = 0.89; p < 0.05). the quality of reporting in MAs of RCTs of pharmacotherapy for major depressive disorder (MDD) in adults (18-65 years) without comorbidities and examine trends over time.

METHODS

MEDLINE, EMBASE, Healthstar, Psychlit and Cochrane databases were searched (1980-2002) by 4 independent reviewers for MAs of RCTs. Articles meeting inclusion criteria were blinded. Inter-rater reliability (kappa) was evaluated using a test-retest strategy on 4 articles. Quality was (p = 0.74) did not detect a difference in quality of assessed using the QUOROM checklist. Time trends were evaluated by calculating Spearman's rho.

RESULTS

One hundred articles were identified, 68 were excluded [co-morbidities (9), inappropriate comparator (13), inappropriate outcome (15), article not available (5), inappropriate patient population (15), and inappropriate study design (11)]; 32 were included. Initial kappa was 0.81 (p < 0.05). After resolution of disagreements, the test-retest The mean overall quality score was 50.2% (SD 15.8%, range = 16.7-88.9%). The overall score for Titles was very poor (22%), Abstracts (40%) and Methods (49%) were poor, while overall Results score was minimally acceptable (54%). Good quality scores were found for Introduction (91%) and Discussion (97%). No time trends were identified using Spearman's correlation analysis (rho 0.05; p = 0.79). The Mann-Whitney U test articles published before and after the QUOROM.

CONCLUSION

Despite quality guidelines, the average quality of published MAs of antidepressants is barely acceptable (50.2%). A need exists for adherence to standardized reporting and quality guidelines.

Incidences of new prescribing by British child and adolescent psychiatrists: a prospective study over 12 months

Little is known about the epidemiology of pharmacotherapy in the treatment of child psychiatric disorder. This study reports on the systematic prospective collection of instances of new prescribing by child and adolescent mental health services serving a population of approximately four million people in North West England. Diagnostic and demographic information regarding new prescribing by child and adolescent mental health services within Greater Manchester and Lancashire was systematically collected prospectively over two 6-month periods between 2000 and 2002. Within the 12 months studied, there were 845 instances of a drug being newly prescribed to a child or adolescent in the treatment of a psychiatric disorder. In total, 48 different drugs were prescribed for 25 different diagnoses. The eight most commonly prescribed drugs were methylphenidate, methylphenidate/placebo trial, paroxetine, fluoxetine, risperidone, imipramine, dexamphetamine and melatonin, accounting for 73% of all prescribing. There was marked variation between services in the amount of prescribing with significant correlation between prescription of stimulants and prescription of selective serotonin reuptake inhibitor antidepressants. Prescription of medications in the treatment of child psychiatric disorder has become a significant part of child and adolescent mental health practice. However, the evidence base underpinning this usage remains limited, and further high quality therapeutic clinical trials are urgently needed.

Somatic treatment for depressive illnesses in children and adolescents

Numerous somatic interventions have been studied as potential treatments of depressive disorders in children and adolescents. These include antidepressant medications, light therapy, electro-convulsive therapy, and alternative therapies. The available evidence suggests that several somatic interventions hold promise as potentially safe and effective treatments for depressed youths; however, there is still much to be learned about these interventions. This article reviews what is known and what needs to be learned about the somatic treatment of pediatric depression.

Open trial of bupropion SR in adolescent major depression

PROBLEM

There are few studies of sustained-release bupropion in adolescents with major depression.

METHODS

Twenty-one adolescents with DSM-IV major depression were recruited through advertisement and self-referral; 11 began study medication and were rated weekly with an expanded Hamilton Depression Rating Scale (SIGH-SAD), as well as Clinical Global Impression-Improvement (CGI-I).

RESULTS

Of 11 subjects enrolled, 8 completed an 8-week trial of bupropion SR. Mean baseline SIGH-SAD scores of 31.3 decreased significantly by 74% to mean endpoint score of 8.2. Improvement on CGI-I that agreed closely between raters and patients was found in 8 of 11 subjects (72.3%). The mean daily dose of bupropion SR was 362 mg +/- 52 mg and was well tolerated; insomnia and weight loss were experienced by 55%; other adverse effects of dry mouth, headache, agitation, light-headedness, diarrhea, or rash were noted in a minority of subjects.

CONCLUSIONS

In this preliminary, small open study, depressed adolescents showed a marked response to bupropion SR.

Impact of antidepressant side effects on adolescent quality of life

OBJECTIVE

This study examines the relative impact of antidepressant side effects on adolescents with a history of major depression.

METHODS

We used Q-sort methodology to capture the opinions of adolescents with a history of depression (n = 22), adults with a history of depression (n = 20), healthy adolescents (n = 20), and clinicians (n = 18) on the impact of 40 common antidepressant side effects. We asked subjects to force rank the side effects, judging each side effect on its relative impact on their daily lives. We also examined the impact of these side effects on health status and medication compliance. Primary analyses compared adolescents with depression with the other groups on their mean rankings for each of the 40 side effects. Secondary analyses included paired comparisons for ratings on health status and compliance.

RESULTS

Although all groups ranked syncope and vomiting among the worst 5 side effects, significant differences were found between the groups on other side effects, such as anxiety, sleepiness, and hair loss. Based on the side effect with the most negative impact, adolescents with depression judged their own compliance (mean = 22%) to be higher than predicted by clinicians (mean = 11%). There were no significant differences between the groups on the mean rating of health status.

CONCLUSIONS

Adolescents with depression, adults with depression, healthy adolescents, and clinicians agreed on the negative impact of 2 side effects: vomiting and syncope. Q-sort methodology provides valuable insight into the similarities and differences in opinion regarding the potential impact of side effects in patient groups.

Major depressive disorder in adolescence: a brief review of the recent treatment literature

OBJECTIVE

Treating adolescents with depression remains a major clinical and public health challenge. Because of the serious morbidity and mortality associated with adolescent major depressive disorder (MDD), there is a need to review the published literature on treatment efficacy to establish effective treatment choices for these adolescents.

METHOD

We reviewed the recent literature on the treatment of MDD in adolescents using the Medline and PsycINFO computerized databases.

RESULTS

Results of open studies of MDD treatment in adolescents suggested therapeutic efficacy; however, later, better-controlled studies are more difficult to interpret, owing to the high rate of improvement with placebo. Currently, there is limited evidence of robust, effective therapeutic interventions in children and in adolescent depressive disorders.

CONCLUSIONS

Despite limitations, current findings from studies investigating selective serotonin reuptake inhibitors (SSRIs), cognitive-behavioural therapy, and interpersonal therapy generally support these treatments as safe and effective for adolescent MDD. Still, further investigations into these treatments for adolescent depression are warranted.

Diagnosis and treatment of chronic depression in children and adolescents

Chronic unipolar depression is being increasingly recognized in general psychiatry as a particularly severe form of depressive illness that leads to significant symptomatology, prolonged suffering, and prolonged functional impairment in a variety of domains, including educational/vocational dysfunction as well as interpersonal impairment. Recent research on treatment interventions for adult patients with chronic depressions suggests that standard treatments for depressive illness may need modification to benefit patients with chronic illness. Little attention at this point has been given to the problem of chronic depression in children and adolescents. Many adults with chronic depressive disorders had onset of depression in their childhood or adolescence, making early identification of this form of illness a priority. The authors present a comprehensive review of emerging literature in the assessment, clinical course, and treatment of chronic forms of unipolar depression in youth. They then develop summary recommendations for the assessment and treatment of this type of mood disorder in youth, based on the currently available research and common sense clinical experience.

A differential response to nortriptyline and fluoxetine in melancholic depression: the importance of age and gender

OBJECTIVE

To consider the impact of age and gender on the antidepressant response to nortriptyline and fluoxetine in melancholic depression.

METHOD

Of 191 depressed patients, 113 met study criteria for melancholia. All patients were randomized to receive either fluoxetine or nortriptyline. Response rates, defined as an improvement of 60% or more on the Montgomery Asberg Depression Rating Scale over 6 weeks of antidepressant treatment on an intention to treat basis, were examined by age, and by age and gender.

RESULTS

Melancholic depressed patients 40 years or older, especially men, had a markedly superior response to nortriptyline compared with fluoxetine. Conversely, melancholic depressed patients, age 18-24 years, especially women, had a markedly superior response to fluoxetine.

CONCLUSION

Age and gender appear to be critical variables in understanding differential antidepressant responses to tricyclic antidepressants and selective serotonin reuptake inhibitors in melancholic depression.

Prescribing Practices in Child and Adolescent Psychiatry: Change Over Time 1993-2000

BACKGROUND

Prescribing practices amongst child and adolescent psychiatrists in other countries appear to have changed in the past 10 years. This study sought to examine changes over the same time period in the UK.

METHOD

A questionnaire survey of prescribing practices of child and adolescent psychiatrists in Oxford Region and Wales was compared with results of a similar survey of Oxford Region 7 years previously.

RESULTS

The notable changes over time were an increase in prescribing to treat Attention Deficit Hyperactivity Disorder and an increase in prescribing of selective serotonin reuptake inhibitors for the treatment of depression. The findings between Oxford and Wales in the year 2000 were similar, suggesting that these findings may be generalised throughout Britain.

CONCLUSIONS

Prescribing practices in the UK may have changed in the past decade with more use of stimulants and SSRIs. This is similar to the changes noted in the USA.

Annotation: The use of psychotropic medications in children: a British view

BACKGROUND

Prescribing practices relating to the use of psychotropic medication with mentally disordered children have changed significantly in Britain over recent years.

METHODS

I conducted a review of the modest body of empirical data available relating to the prescribing practices of child psychiatrists, paediatricians and general practitioners (primary care physicians). The data were obtained primarily from postal questionnaire studies but also from British drug studies and a government-sponsored evaluation of the efficacy of stimulant medication. Postgraduate training guidelines for the three principal clinical disciplines are also discussed.

RESULTS

Systematic evaluation of prescribing practices has a relatively short history. All the studies reviewed demonstrated consistent methodological weaknesses, the most important of which was reliance upon retrospective reports of prescribing practices from clinicians with no analysis of actual prescription data. No studies relating to the general use of psychotropic medication by paediatricians were found. Child psychiatrists and general practitioners appear to be using a range of drugs for a range of conditions; however, there was evidence of intra- and interdisciplinary variations in practice. It was also evident from the general practitioner data that drug treatments were frequently used for conditions best managed with behavioural methods (e.g., common sleep problems and enuresis). Government prescription data relating to methylphenidate use in ADHD reveal a dramatic rise over the past ten years. Currently, most child psychiatrists use this treatment compared to approximately half the profession only seven years ago. The use of newer antipsychotic agents as well as the SSRI antidepressants appears to be growing in child psychiatric practice. A majority of clinicians surveyed believed that medication was an important treatment modality but also felt that they were relatively unskilled in the field and requested further training.

CONCLUSIONS

Overall, a picture of both a growing and better informed use of psychotropic medication is emerging in Britain despite shortcomings in postgraduate training. Future research needs to evaluate prescribing practice in a more objective manner in order to improve training and also service developments in the field.

Side effects of desipramine and age

INTRODUCTION

The treatment response of children and adolescents to tricyclic antidepressants differs from that of adults. Few data exist on the impact of age on side effects. This study compares desipramine-associated side effects in children, adolescents, and adults.

METHODS

Data from three trials of desipramine were combined to produce a sample of 148 subjects, aged 7 to 66 years. Pulse and blood pressure were measured at baseline and while participants were receiving desipramine. Side effects were rated by a clinician. For data analysis, subjects were divided into two groups, younger patients (18 and younger) and older patients (19 and older). Group means of side effect ratings and vital signs were compared. Results were also analyzed covarying for plasma levels of desipramine.

RESULTS

There were significant differences between younger and older patients in pulse and blood pressure at baseline, on desipramine, and in changes in vital signs between baseline and medicated states. Younger patients had significantly lower mean ratings for constipation and dry mouth.

DISCUSSION

Treatment with desipramine results in differing degrees of subjective side effects and changes in vital signs across the life cycle. Physicians should not assume that side effects experienced by children and adolescents are identical to those experienced by adults.

A comparison of active drugs for the treatment of dysthymia

BACKGROUND

Many drug treatments have been proposed for the treatment of dysthymia, but with so many potential comparisons it is not possible at the present time to determine which is the treatment of choice. There is a need to know whether the different classes of antidepressants have similar efficacy. In addition, the tolerability of treatments may be even more important, since dysthymia is a chronic condition characterised by less severe symptoms than major depression.

OBJECTIVES

To conduct a systematic review of all randomised controlled trials comparing two or more active drug treatments for dysthymia.

SEARCH STRATEGY

Electronic searches of Cochrane Library, EMBASE, MEDLINE, PsycLIT and LILACS, Biological Abstracts; reference searching; personal communication; unpublished trials from pharmaceutical industry.

SELECTION CRITERIA

Only randomised and quasi-randomised controlled trials were included. Trials had to compare at least two active drug treatments in the treatment of dysthymia. Exclusion criteria were: non-randomised studies, studies which included patients with mixed major depression/dysthymia and studies on depression/dysthymia secondary to other disorders (e.g. substance abuse).

DATA COLLECTION AND ANALYSIS

The reviewers extracted the data independently and odds ratios, weighted mean difference and number needed to treat were estimated. The reviewers assumed that people who died or dropped out had no improvement and tested the sensitivity of the final results to this assumption.

MAIN RESULTS

A total of 14 trials were eligible for inclusion in the review. All studied drugs promoted similar clinical responses, although with different side effect profiles. The evidence for TCAs and SSRIs was the most robust, considering the number of trials and participants.

REVIEWER'S CONCLUSIONS

The conclusion is that the choice of drug must be made based on consideration of drug-specific side effect properties.

A comparison of antidepressant trials using active and inert placebos

In placebo-controlled antidepressant trials, there are concerns that the double blind may be breached, which may bias results. Some trials have therefore used placebos containing active substances in order to mimic the side effects of antidepressants. This study set out to examine the impact of 'unblinding' by comparing the results of a meta-analysis of a sample of trials using ordinary inert placebos with a meta-analysis of trials using active placebos. An a priori sub-group analysis of trials conducted with inpatients and outpatients was carried out. Quality was assessed using a quality assessment instrument and meta-regression analysis was conducted to explore heterogeneity. Results of meta-analysis did not differ between trials using active placebos and trials using inert ones. However, results were strongly influenced by two large trials. When these were excluded trials using inert placebos showed greater antidepressant-placebo differences than trials using active placebos. There was very high heterogeneity especially among trials using inert placebos. Meta-regression analysis showed the only significant predictor of outcome was whether trials were conducted with inpatients or outpatients. Sub-group analysis showed significant differences between antidepressants and any type of placebo in trials conducted with outpatients but not in inpatient trials. Lack of data, heterogeneity and the influence of large studies limited the analysis. The integrity of the double blind design, its effect on results and the heterogeneity between studies, require further exploration in antidepressant trials.

National prescribing practices of adolescent psychiatrists for psychotropic medications in outpatient care in Finland

We studied national prescribing practices for psychotropic drugs in adolescent psychiatric outpatient care in Finland in the cross-sectional survey study in 1999. A questionnaire was sent to the adolescent psychiatrists employed in the community outpatient clinics covering all Finland. The response rate was 81% (n=34). On average, the respondents reported that 33% of their outpatients were treated with drugs. Selective serotonin reuptake inhibitors (SSRIs) were the drug of choice in the treatment of depression and obsessive-compulsive disorder (OCD). Atypical antipsychotics played an important role in the treatment of psychotic adolescents. Adolescent psychopharmacology is an important and developing part of treatment of mentally disordered young people, on the understanding that drug therapies are adjunct to other treatment interventions.

Implementing a randomized clinical trial on a pediatric psychiatric inpatient unit at a children's hospital: the case of clonidine for post-traumatic stress

Randomized clinical trials (RCTs) of psychotropic medications are uncommon among child and adolescent populations, and even rarer on pediatric, psychiatric inpatient units. We mention some of these studies, and then discuss the advantages and challenges of conducting a RCT among youngsters on an inpatient psychiatric unit in a pediatric hospital, using as an example our ongoing study of clonidine for intrusive symptoms of post-traumatic stress. Our purpose is to alert potential investigators to the obstacles they may encounter while implementing a RCT, while also pointing the way to potential resources. Advantages of inpatient units for RCTs include easy access to patients, with the potential for careful monitoring of both patients' clinical status and of medication administration. Challenges include the need for the psychiatric researcher to form liaison with other important areas within the hospital, such as the Institutional Review Board, the Pharmacy, and sometimes a General Clinical Research Center and a Clinical Research Program. The functions of these departments are discussed, and additional support for clinicians in hospital settings without these departments is described. Other issues include training clinical nurses to conduct research while making adequate provisions for their time to do so. Attitudes on a clinical psychiatric inpatient unit toward research also merit consideration. Furthermore, as with any study in a hospital setting, recruitment presents its own set of challenges. Finally, one must be cognizant of how clinical information flows between clinicians and researchers.

Clinical practice guidelines for depression in young people: are the treatment recommendations outdated?

The 1997 NHMRC clinical practice guidelines for depression in young people included recommendations for treatment that need to be modified in light of more recent research. Changes to the guidelines should include the findings that selective serotonin reuptake inhibitors and some forms of psychotherapy are effective in treating adolescent depression. It is increasingly recognised that depression in adolescents often recurs and that prevention of recurrences should be a priority for research and practice.

Annotation: randomised trials

BACKGROUND

This annotation describes the uses of randomised controlled trials (RCTs) in clinical child psychology and psychiatry.

METHOD

It explores the scientific basis for randomised designs, the conceptual and methodological issues that can arise when using them, alternative methods, and future directions.

RESULTS

There are many issues that have to be tackled when using randomised trials to answer questions about the effectiveness of interventions used by child mental health professionals. The most important are conceptual issues concerning the design of these studies, practical issues, and issues about the interpretation of the results. There are some situations in which randomised trials are not possible or ideal and alternative strategies may therefore be needed. Future RCTs should be more explicit about whether their primary purpose is to further scientific knowledge or to evaluate the benefit of a treatment in routine clinical practice. Future trials should also have outcomes of unequivocal significance and be reported in accordance with standardised guidelines.

CONCLUSIONS

Well-designed and unambiguously reported RCTs usually provide the best possible evidence about the effectiveness of an intervention. RCTs are not, however, the only way of establishing cause and effect and their results should always be interpreted in the light of other evidence.

Psychosocial and clinical predictors of response to pharmacotherapy for depression

A more complete understanding of the psychosocial and clinical predictors of response to pharmacotherapy would be of great value to both patients and physicians. Most demographic and clinical factors have not been found to be useful predictors of response. Although comorbid illness affects quality of life, there is confounding evidence about its importance when predicting response to antidepressant therapy. Some social support factors appear to be positive predictors of outcome in most trials. There is evidence to suggest that comorbid anxiety disorders and panic-agoraphobic spectrum symptoms are negative predictors of response to treatment. Substance abuse has been associated with a poorer response to antidepressant therapy, and recovery from substance abuse problems has been shown to be poorer among patients with comorbid depression. Assessment of personality dimensions may be a useful predictor of clinical course and outcome, but personality disorders present a complicated picture, with significant interaction among variables. A number of variables are significantly related to clinical course, but few factors have been clearly linked to treatment response. The challenge is to determine if any of these factors are indeed independent predictors of response and whether it is possible to match choice of antidepressant therapy and patient type.

Rising prevalence of antidepressants among US youths

OBJECTIVE

To examine changes in antidepressant (ATD) prevalence and the sociodemographic and clinical correlates of ATD use among youths who are treated in community practice settings.

METHODS

A retrospective study was undertaken using large data sets from 3 US sites. Outpatient prescription and clinical service records of youths who were aged 2 to 19 and enrolled in Midwestern Medicaid (MWM) and mid-Atlantic Medicaid (MAM) state programs and a group-model health maintenance organization (HMO) were organized into seven 1-year cross-sectional data sets from 1988 through 1994 to evaluate ATD utilization patterns.

RESULTS

In 1994, ATD prevalence per 1000 youths was 19.10 (MWM), 17.78 (MAM), and 12.85 (HMO), which represented a consistent increase in prevalence from 1988-1994: 2.9-fold (MWM), 4.6-fold (MAM), and 3.6-fold (HMO). Despite the rapidly expanding use of selective serotonin reuptake inhibitors prescribed mainly for depression, more than half of ATD use in 1994 was still attributable to tricyclic antidepressants prescribed mainly for attention-deficit/hyperactivity disorder. ATD prevalence was generally predominant among 10- to 14-year-old boys and among 15- to 19-year-old girls. In the Medicaid populations, 42% (MAM) and 72% (MWM) of ATD-treated youths had primary care services, whereas the bulk of the remainder had psychiatric services. Attention-deficit/hyperactivity disorder followed by depression led the physician-reported primary care diagnoses associated with ATD use, whereas that diagnostic rank order was reversed for youths who received psychiatric services.

CONCLUSIONS

ATD treatments among youths substantially increased in the 1990s. This was generated primarily by primary care providers, and thus evaluations of the outcome of ATD treatment need to target primary care in addition to psychiatric providers. Longitudinal study designs are needed to evaluate the use of ATDs in youths in regard to the duration of treatment, combination medications, and the reasons for treatment.

Tricyclic drugs for depression in children and adolescents

BACKGROUND

There is a need to identify effective and safe treatments for depression in children and adolescents. While tricyclic drugs are effective in treating depression in adults, individual studies involving children and adolescents have been equivocal.

OBJECTIVES

To assess the effects of oral tricyclic antidepressants compared to placebo in the treatment of child and adolescent depression.

SEARCH STRATEGY

We searched MEDLINE (1966-1997), EMBASE, Excerpta Medica (June 1974-1997), the Cochrane Collaboration Depression, Anxiety and Neurosis Group trials register (most recent search 25/1/2000) and bibliographies of previously published reviews and papers describing original research were cross-checked. Current Contents was screened for recent publications. We contacted authors of relevant abstracts in conference proceedings of the American Academy of Child and Adolescent Psychiatry, and we hand searched the Journal of the American Academy of Child and Adolescent Psychiatry (1978-1999).

SELECTION CRITERIA

Randomised controlled trials comparing the efficacy of orally administered tricyclic medication with placebo in depressed people aged 6-18 years.

DATA COLLECTION AND ANALYSIS

Most studies reported multiple outcome measures including depression scales and clinical global impression scales. For each study the best available depression measure was taken as the index measure of depression outcome. Predetermined criteria were established to assist in the ranking of measures. Where authors reported categorical outcomes we calculated individual and pooled odds ratios for the odds of improvement in treated compared with control subjects. For continuous outcomes pooled effect sizes were calculated as the number of standard deviations by which the change in depression scores for the treatment group exceeded those for the control groups.

MAIN RESULTS

Thirteen trials (involving 506 participants) were included. No overall improvement with treatment compared to placebo was seen for children or adolescents (odds ratio = 0.84, 95% confidence interval 0.56 to 1.25). A statistically significant but small benefit of treatment over placebo was seen in reducing symptoms (effect size (standardised mean difference) = -0.31, 95% confidence interval -0.62 to -0.01). Subgroup analyses suggest a larger benefit among adolescents (effect size = -0.47, 95% confidence interval -0.92 to -0.02), and no benefit among children (effect size = 0.15, 95% confidence interval -0.34 to 0.64). Treatment with a tricyclic antidepressant caused more vertigo (odds ratio = 4.38, 95% confidence interval 2.33 to 8.25), orthostatic hypotension (odds ratio = 6.78, 95% confidence interval 2.06 to 22.26), tremor (odds ratio 6.29, 95% confidence interval 1.78 to 22.17) and dry mouth (odds ratio = 5.17, 95% confidence interval 2.68 to 29.99) than did placebo, but no statistically significant difference was found for other possible adverse effects.

REVIEWER'S CONCLUSIONS

Data suggest tricyclic antidepressants are not useful in treating depression in pre pubertal children. There is marginal evidence to support the use of tricyclic antidepressants in the treatment of depression in adolescents, although the magnitude of effect is likely to be moderate at best.

Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial

OBJECTIVE

To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression.

METHOD

After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores.

RESULTS

Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects.

CONCLUSIONS

Paroxetine is generally well tolerated and effective for major depression in adolescents.

Are child-, adolescent-, and adult-onset depression one and the same disorder?

This paper reviews prior research studies examining neurobiological correlates and treatment response of depression in children, adolescents, and adults. Although there are some similarities in research findings observed across the life cycle, both children and adolescents have been found to differ from depressed adults on measures of basal cortisol secretion, corticotropin stimulation post-corticotropin releasing hormone (CRH) infusion, response to several serotonergic probes, immunity indices, and efficacy of tricyclic medications. These differences are proposed to be due to 1) developmental factors, 2) stage of illness factors (e.g., number of episodes, total duration of illness), or 3) heterogeneity in clinical outcome (e.g., recurrent unipolar course vs. new-onset bipolar disorder). Relevant clinical and preclinical studies that provide support for these alternate explanations of the discrepant findings are reviewed, and directions for future research are discussed. To determine whether child-, adolescent-, and adult-onset depression represent the same condition, it is recommended that researchers 1) use the same neuroimaging paradigms in child, adolescent, and adult depressed cohorts; 2) carefully characterize subjects' stage of illness; and 3) conduct longitudinal clinical and repeat neurobiological assessments of patients of different ages at various stages of illness. In addition, careful attention to familial subtypes (e.g., depressive spectrum disorders vs. familial pure depressive disorders) and environmental factors (e.g., trauma history) are suggested for future investigations.

Mood disorders in children and adolescents: psychopharmacological treatment

Mood disorders are the leading causes of morbidity and mortality in children and adolescence. As a result, many adolescents are treated with psychopharmacologic agents such as antidepressants and mood stabilizers. To date, research into the safety and efficacy of these medications has lagged behind clinical practice. Several controlled trials of antidepressants in this population have recently been completed or are ongoing, yet few controlled trials of mood stabilizers have been conducted. Although acute efficacy of antidepressants is being addressed, many questions remain about pharmacological treatment of early-onset mood disorders. This article will focus on unmet research needs for the psychopharmacologic treatment of child and adolescent mood disorders.

Antidepressant treatment in children and adolescents: bridging the gap between efficacy and effectiveness

This review of antidepressant treatments in children and adolescents emphasizes the gap between efficacy data derived from randomized clinical trials (RCTs) and the limited effectiveness data from community-based practices. Part one is a brief review of data from randomized, double-blind clinical trials to assess the evidence base for the major approved indications for antidepressants in youths. Part two reviews information gaps in the evidence from RCTs. Part three discusses nonexperimental evidence of the use of antidepressants, including surveys of prescription sales, physician surveys, and population-based data. Part four presents a comprehensive model for assessing the use of antidepressants in youths in the community. The model aims to answer a range of public health-oriented questions and is intended to improve treating physicians' and clinical care providers' ability to manage medications for optimal patient benefit. Suggestions are made for engaging health service providers, health insurers, academicians, advocates, and the government in building the necessary infrastructure to make effectiveness as vital as efficacy to the model of drug therapy evaluation.

Tricyclic antidepressants and selective serotonin reuptake inhibitors: use during pregnancy, in children/adolescents and in the elderly

OBJECTIVE

Depressive disorders can occur at any point in the lifespan. One way of differentiating antidepressants is by examining their efficacy and safety in the special patient populations that exist along the lifespan. Thus, we examine clinical data that is available regarding the use of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) at three distinct points in the lifespan: childhood and adolescence, pregnancy and late adulthood.

METHOD

Literature regarding the use of antidepressants in children and adolescents, pregnancy and the elderly was reviewed.

RESULTS

Clinical data suggest that SSRIs should be first line treatment in children and adolescents as TCAs have questionable efficacy and definite safety issues. Similarly, although TCAs and SSRIs show equivalent efficacy in elderly patients, the safety profile of the SSRIs makes them a more prudent choice in this population. Finally, although there is no definitive data that contraindicates the use of a particular antidepressant in pregnancy, the bulk of reassuring pregnancy outcome data exists for the SSRIs, specifically for fluoxetine.

CONCLUSION

Although no single antidepressant can ever be recommended for every patient, SSRIs should be considered the first-line choice in the treatment of depression in special patient populations.

Childhood depression: pharmacological therapy/treatment (pharmacotherapy of childhood depression)

Critiqued the published double-blind, placebo-controlled studies of antidepressant pharmacotherapy in child and adolescent major depressive disorder to assess their overall efficacy. The pharmacological mechanism of antidepressant action also was discussed. At best, antidepressant treatment for depressed youths is only modestly effective. In particular, the tricyclic antidepressants are not superior to placebo; however, early evidence with the selective serotonin reuptake inhibitors is more encouraging. The theoretical basis for this response pattern is discussed from a methodological perspective, from a neurodevelopmental status, and from a biological viewpoint. Study modifications are suggested which could improve some of the methodological limitations apparent in previous clinical drug trials.

Depression, suicide and deliberate self-harm in adolescence

The past decade has seen important advances in research into the epidemiology, aetiology and treatment of depression and suicidal behaviour in the young. We are beginning to understand how risk factors combine to precipitate and maintain these problems. There is rarely a linear relationship between causes and outcomes. Rather, the cause is usually a combination of predisposing constitutional factors arising from genetic endowment or earlier experience and precipitating stressful events. These aetiological factors act through biochemical, psychological and social processes to produce the outcome. Progress has also been in the development of a range of effective treatments, such as 'here and now' psychological treatments and antidepressants. All depressed or suicidal young people require careful assessment. Some will require a brief intervention only. Others, however, will require more intensive and lengthy forms of treatment.

The challenge of diagnosing depression in childhood and adolescence

Depression is a significant psychiatric disorder in children and adolescents which can result in serious consequences such as school absenteeism and decreased educational attainment. Recent studies have shown that children and adolescents present with a different spectrum of symptoms than adults with depression. Furthermore, depression in the young is more frequently comorbid with other psychiatric disorders than in adult patients, further complicating diagnosis. Once the condition is diagnosed, it is clear that treatment is necessary. Although early clinical data suggest that selective serotonin reuptake inhibitors (SSRIs) or psychotherapy may provide effective treatment, further clinical trials are required in young patients.

A simple method for converting an odds ratio to effect size for use in meta-analysis

A systematic review may encompass both odds ratios and mean differences in continuous outcomes. A separate meta-analysis of each type of outcome results in loss of information and may be misleading. It is shown that a ln(odds ratio) can be converted to effect size by dividing by 1.81. The validity of effect size, the estimate of interest divided by the residual standard deviation, depends on comparable variation across studies. If researchers routinely report residual standard deviation, any subsequent review can combine both odds ratios and effect sizes in a single meta-analysis when this is justified.

Therapeutic effects and tolerability of fluvoxamine treatment in adolescents with dysthymia

OBJECTIVE

The aim of the study was to evaluate therapeutic effects and tolerability of fluvoxamine (150-200 mg daily) in 21 dysthymic adolescents.

SUBJECTS

Twenty-one adolescents, attending psychiatric clinics, who met DSM-III-R criteria for dysthymia, without significant co-morbidity were the subjects.

METHODS

Axis I and II diagnoses were made by using SCID-P and SCID II. Score A of >13 on HAMD-S at baseline was mandatory. The HAMD-S was completed after 4, 8, and 26 weeks. Adverse effects were recorded after 1, 2, 4, and 8, weeks. Tolerability was assessed by using CGI-T after 1, 2, and 4 weeks. Adverse effects caused three subjects to withdraw from the study.

RESULTS

Good clinical response (decrease of HAMD-S score >50%) was observed after 4 weeks in 48% of patients; after 8 weeks in 56% of patients, and after 26 weeks in 44% patients. Relapse occurred in 34% of subjects. Fluvoxamine was well tolerated in 76.2% of the adolescents; poor toleration resulted in its discontinuation in 14.2% adolescents.

The adolescent brain and age-related behavioral manifestations

To successfully negotiate the developmental transition between youth and adulthood, adolescents must maneuver this often stressful period while acquiring skills necessary for independence. Certain behavioral features, including age-related increases in social behavior and risk-taking/novelty-seeking, are common among adolescents of diverse mammalian species and may aid in this process. Reduced positive incentive values from stimuli may lead adolescents to pursue new appetitive reinforcers through drug use and other risk-taking behaviors, with their relative insensitivity to drugs supporting comparatively greater per occasion use. Pubertal increases in gonadal hormones are a hallmark of adolescence, although there is little evidence for a simple association of these hormones with behavioral change during adolescence. Prominent developmental transformations are seen in prefrontal cortex and limbic brain regions of adolescents across a variety of species, alterations that include an apparent shift in the balance between mesocortical and mesolimbic dopamine systems. Developmental changes in these stressor-sensitive regions, which are critical for attributing incentive salience to drugs and other stimuli, likely contribute to the unique characteristics of adolescence.

Preventive interventions for youth suicide: a risk factor-based approach

OBJECTIVE

This review draws on current knowledge of risk for youth suicide to categorize strategies for intervention. Its goal is to identify areas of 'research need' and to provide an evidence base to identify 'best buy' preventive interventions for youth suicide.

METHOD

The design, development, implementation and evaluation of prevention strategies ranging from clinical interventions to population-based universal approaches are considered within five risk factor domains: individual, family, community, school and peer.

RESULTS

There is a paucity of evidence on the effects of interventions targeting depression and suicidal behaviour. Nevertheless, there are effective indicated, selective and universal interventions for important risk factors for depression and suicidal behaviour. Little evidence has emerged to support the efficacy of some traditional approaches to suicide prevention, such as school based suicide education programs and telephone hotlines.

CONCLUSIONS

Youth suicide prevention strategies in Australia have generally employed traditional approaches that focus on clinical interventions for self-harmers, restricting access to lethal means, providing services to high risk groups and enhancing general practitioner responses. Both program development and research evaluation of interventions for many important risk and protective factors for suicide have been neglected.

Therapeutic drug monitoring of psychotropic medications

Therapeutic drug monitoring (TDM) of a number of psychotropic medications has proven to be of value, enabling minimization of the limitations of considerable genetic variability in their metabolism and the high rates of poor compliance with many psychiatric disorders. Therapeutic ranges have been established for lithium, some of the tricyclic antidepressants, and clozapine. TDM has also been shown to be useful in avoiding toxicity (as many psychotropics have narrow therapeutic indices), particularly that due to interactions with other compounds.

Changes in autonomic regulation with age: implications for psychopharmacologic treatments in children and adolescents

Developmental changes in the cardiovascular system could have an impact on risks associated with psychopharmacological interventions. Children may be more vulnerable to adverse cardiac events due to immaturity in autonomic control of the heart. These changes are incompletely understood and are characterized in this study. A consecutive series of 70 boys, aged 6-14 years, was recruited. Developmental variation in the autonomic nervous system was evaluated by assessing heart period variability (HPV), pulse, and blood pressure in response to orthostasis. Increased age correlated significantly with greater heart rate and diastolic blood pressure response to orthostasis. HPV at rest and in response to tilt did not significantly correlate with age. Boys with family histories of hypertension had a significantly greater blood pressure response to orthostasis. These findings suggest that developmental age-related changes in the sympathetic nervous system, as reflected by changes of pulse and blood pressure response to tilt, occur across this age range. Parasympathetic changes, as reflected by HPV, do not. In light of these findings, more research is needed on children's and adolescents' relative cardiac risk with psychotropic medications as opposed to adults'.