Fluoxetine 40-60 mg versus fluoxetine 20 mg in the treatment of children and adolescents with a less-than-complete response to nine-week treatment with fluoxetine 10-20 mg: a pilot study

Special Populations: Treatment-Resistant Depression in Children and Adolescents

Major depressive disorder is a substantial public health challenge impacting at least 3 million adolescents annually in the United States. Depressive symptoms do not improve in approximately 30% of adolescents who receive evidence-based treatments. Treatment-resistant depression in adolescents is broadly defined as a depressive disorder that does not respond to a 2-month course of an antidepressant medication at a dose equivalent of 40 mg of fluoxetine daily or 8 to 16 sessions of a cognitive behavioral or interpersonal therapy. This article reviews historical work, recent literature on classification, current evidence-based approaches, and emerging interventional research.

Restoring the two pivotal fluoxetine trials in children and adolescents with depression

BACKGROUND

Fluoxetine was approved for depression in children and adolescents based on two placebo-controlled trials, X065 and HCJE, with 96 and 219 participants, respectively.

OBJECTIVE

To review these trials, which appear to have been misreported.

METHODS

Systematic review of the clinical study reports and publications. The primary outcomes were the efficacy variables in the trial protocols, suicidal events, and precursors to suicidality or violence.

RESULTS

Essential information was missing and there were unexplained numerical inconsistencies. (1) The efficacy outcomes were biased in favour of fluoxetine by differential dropouts and missing data. The efficacy on the Children's Depression Rating Scale-Revised was 4% of the baseline score, which is not clinically relevant. Patient ratings did not find fluoxetine effective. (2) Suicidal events were missing in the publications and the study reports. Precursors to suicidality or violence occurred more often on fluoxetine than on placebo. For trial HCJE, the number needed to harm was 6 for nervous system events, 7 for moderate or severe harm, and 10 for severe harm. Fluoxetine reduced height and weight over 19 weeks by 1.0 cm and 1.1 kg, respectively, and prolonged the QT interval.

CONCLUSIONS

Our reanalysis of the two pivotal trials showed that fluoxetine is unsafe and ineffective.

Forks in the road: Definitions of response, remission, recovery, and other dichotomized outcomes in randomized controlled trials for adolescent depression. A scoping review

BACKGROUND

Definitions of dichotomous outcome terms, such as "response," "remission," and "recovery" are central to the design, interpretation, and clinical application of randomized controlled trials of adolescent depression interventions. Accordingly, this scoping review was conducted to document how these terms have been defined and justified in clinical trials.

METHOD

Bibliographic databases MEDLINE, Embase, APA PsycInfo, and CINAHL were searched from inception to February 2020 for randomized controlled trials evaluating treatments for adolescent depression. Ninety-eight trials were included for data extraction and analysis.

RESULTS

Assessment of outcome measurement instruments, metric strategies, methods of aggregation, and measurement timing, yielded 53 unique outcome definitions of "response" across 45 trials that assessed response, 47 unique definitions of "remission" in 29 trials that assessed remission, and 19 unique definitions of "recovery" across 11 trials that assessed recovery. A minority of trials (N = 35) provided a rationale for dichotomous outcomes definitions, often by citing other studies that used a similar definition (N = 11). No rationale included input from youth or families with lived experience.

CONCLUSION

Our review revealed that definitions of "response," "remission," "recovery," and related terms are highly variable, lack clear rationales, and are not informed by key stakeholder input. These limitations impair pooling of trial results and the incorporation of trial findings into pragmatic treatment decisions in clinical practice. Systematic approaches to establishing outcome definitions are needed to enhance the impact of trials examining adolescent depression treatment.

A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders

BACKGROUND

Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn't working well-whether to optimize the treatment already begun or to add the other treatment.

METHODS

This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8-17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first ("Main Effect 1"). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment ("Main Effect 2"). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone.

DISCUSSION

Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders.

TRIAL REGISTRATION

This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .

A systematic review of interventions for treatment resistant major depressive disorder in adolescents

To update a comparative effectiveness review (1980-2011) of treatments for adolescents whose depressive episode or disorder (MDE/MDD) did not respond to one or more trials of SSRI antidepressants. MEDLINE, Cochrane Central, PsychINFO, Cochrane Database of Systematic Reviews, EMBASE, CINAHL, and AMED were searched in addition to the grey literature. We spanned May 2011 to September 1, 2017 and included only articles in English. 11 new studies were reviewed based on the criteria of having tested a comparative treatment in adolescents with MDD or MDE who were confirmed to have failed one or more SSRI trials. Data were extracted using standardized forms and a reference guide in DistillerSR; a second reviewer verified the accuracy of the data fields and discrepancies were resolved by consensus. One trial (N = 29) found a small benefit of escalating doses of fluoxetine and the treatment of adolescent depression study (TORDIA, N = 334) found significant benefits of combined SSRI or venlafaxine treatment with CBT for most outcomes. No new studies were identified since the previous review (2012). One trial is currently registered that will be a cross over trial of rTMS; other registered trials are open label. Multiple secondary data analyses of TORDIA have identified important predictors of treatment response and relapse. No new comparative studies were identified since the original review. Trials are desperately needed to identify new treatments for youth with SSRI resistant MDD. These youth should not be deemed as treatment resistant until completing one or two failed trials of SSRI combined with evidence-based psychotherapy.

Annual Research Review: Defining and treating pediatric treatment-resistant depression

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.

Pharmacotherapy of adolescent depression - fluoxetine monotherapy or combined treatment?

Depressive disorder is one of the most common and serious psychiatric diagnosis in paediatric population, often connected with suicidal risk. In recent years, fluoxetine monotherapy is the gold standard in acute phase of depression treatment in children and adolescents, but is not effective enough after an acute phase of treatment. More helpful researches concerning more effective therapeutic strategies of depression in this age are insufficient. The aim of our study is to evaluate the effectiveness and safety of fluoxetine monotherapy in comparison with combined olanzapine/fluoxetine therapy in acute 6-week treatment of depression in adolescence. We found that combined therapeutic strategy, using olanzapine augmentation is predicted to be more useful in the treatment of adolescent depression.

Is atomoxetine effective in some comorbid mental disorders in ADHD?

Attention-Deficit/Hyperactivity Disorder (ADHD) is connected with high level of psychiatric comorbidity in paediatric population. Depressive disorder is common comorbid disorder co-existing with ADHD. Atomoxetine is worldwide approved for treatment of ADHD in paediatric population; in addition atomoxetine is effective and safe in treatment of some comorbid disorders in ADHD. Pharmacotherapy of depression is limited and residual symptoms are common. Fluoxetine is currently considered to be the gold standard of treatment of depression, but effectiveness of acute phase of treatment is not sufficient. Atomoxetine as a selective noradrenaline reuptake inhibitor or olanzapine as a multi receptors antagonist drug in combination with fluoxetine could be perspective augmented treatment strategy of depression just for their antidepressant effect. The aim of our following study is to evaluate and compare effectiveness and safety of monotherapy and combined/augmented therapy in acute phase of depression treatment in adolescence, as well as introduce complex modern research methodology of effectiveness and safety of treatment.

Systematic Review and Meta-Analysis: Early Treatment Responses of Selective Serotonin Reuptake Inhibitors in Pediatric Major Depressive Disorder

OBJECTIVE

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for pediatric major depressive disorder (MDD). We conducted a meta-analysis to examine the following: the time-course of response to SSRIs in pediatric depression; whether higher doses of SSRIs are associated with an improved response in pediatric depression; differences in efficacy between SSRI agents; and whether the time-course and magnitude of response to SSRIs is different in pediatric and adult patients with MDD.

METHOD

We searched PubMed and CENTRAL for randomized controlled trials comparing SSRIs to placebo for the treatment of pediatric MDD. We extracted weekly symptom data from trials to characterize the trajectory of pharmacological response to SSRIs. Pooled estimates of treatment effect were calculated based on standardized mean differences between treatment and placebo groups.

RESULTS

The meta-analysis included 13 pediatric MDD trials with a total of 3,004 patients. A logarithmic model indicating that the greatest benefits of SSRIs occurred early in treatment best fit the longitudinal data (log[week] = 0.10, 95% CI = 0.06-0.15, p < .0001). There were no significant differences based on maximum SSRI dose or between particular SSRI agents. SSRIs were demonstrated to have a smaller benefit in pediatric compared to adult MDD.

CONCLUSION

Treatment gains in pediatric MDD are greatest early in treatment and are, on average, minimal after 4 weeks of SSRI pharmacotherapy in pediatric MDD. Further research is needed using individual patient data to examine the power of early SSRI response (e.g., 2-4 weeks) to predict outcomes in short-term pharmacological trials.

A double-blind efficacy and safety study of duloxetine flexible dosing in children and adolescents with major depressive disorder

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety of duloxetine flexible dose in children (7-11 years) and adolescents (12-17 years) with major depressive disorder (MDD).

METHODS

Patients (n=337) in this 36 week study (10 week acute and 26 week extension treatment) received duloxetine (60-120 mg once daily [QD], n=117), fluoxetine (20-40 mg QD, n=117), or placebo (n=103). Measures included: Children's Depression Rating Scale-Revised (CDRS-R), treatment-emergent adverse events (TEAEs), and Columbia-Suicide Severity Rating Scale (C-SSRS).

RESULTS

Neither active drug (duloxetine or fluoxetine) separated significantly (p<0.05) from placebo on mean change from baseline to end-point (10 weeks) on the CDRS-R total score. There were no significant differences between the duloxetine or fluoxetine groups compared with placebo on serious AEs (SAEs), total TEAEs, or discontinuation for AE during acute treatment. There were no completed suicides or deaths, and no clinically significant electrocardiogram (ECG) abnormalities observed during the study. One fluoxetine and one duloxetine patient experienced alanine aminotransferase (ALT) three or more times the upper limit of normal, which resolved during the study. A total of 8 (7.1%) duloxetine patients, 7 (6.8%) placebo patients, and 9 (8.0%) fluoxetine patients had worsening of suicidal ideation from baseline during acute treatment. Of the patients with suicidal ideation at baseline, 15/19 (79%) duloxetine, 19/19 (100%) placebo, and 16/19 (84%) fluoxetine had improvement in suicidal ideation at end-point during acute treatment. One duloxetine and two fluoxetine patients had treatment-emergent suicidal behavior during the 36 week study.

CONCLUSION

Trial results were inconclusive, as neither the investigational drug (duloxetine) nor the active control (fluoxetine) separated from placebo on the CDRS-R at 10 weeks. No new duloxetine safety signals were identified relative to those seen in adults. Clinical Trial Registry Number: NCT00849901.

Psychotherapy, Pharmacotherapy, and Their Combination for Adolescents with Major Depressive Disorder: A Meta-Analysis

This meta-analysis aims to inform clinical practice of treatment strategies for adolescents with major depressive disorder (MDD). The efficacy of three empirically validated treatments was compared to determine the most effective treatment. These were: cognitive-behavioural therapy (CBT), selective serotonin reuptake inhibitor (SSRI) pharmacotherapy, and combination CBT and SSRI therapy. Inclusion criteria required studies to report a reliable and valid pre- and post-treatment measure and adequate data for Hedge's g effect size to be calculated. Forty-nine studies meeting the above inclusion criteria were found and included in the analysis. Although all three treatment strategies were found to be effective, analysis revealed no significant difference in treatment outcome among CBT, SSRI, and combination therapy. An investigation of moderator variables revealed months to follow-up to significantly influence the relationship between treatment type and treatment outcome. Given that CBT has no side effects, is more cost effective, and is equally as effective as SSRI therapy and combination therapy, the current study makes a strong case for CBT as a first-line treatment strategy for adolescents with MDD.

Child and adolescent depression intervention overview: what works, for whom and how well?

The authors review the currently available evidence-based treatments of child and adolescent major depressive disorder. Medication monotherapy, namely with selective serotonin reuptake inhibitors, is supported by large clinical trials in adolescents. For mild to moderate depression, cognitive behavior therapy (CBT) and interpersonal therapy are reasonable options as monotherapies. There is also evidence that the combination of medication and CBT is superior to medication alone for accelerating the pace of treatment response and remission, despite some negative studies. Response, remission, and recurrence rates after acute treatment and during long-term follow-ups are also presented and discussed.

Developmentally informed pharmacotherapy for child and adolescent depressive disorders

This article reviews evidence-based pharmacotherapy for children and adolescents with depression. Several randomized controlled trials (RCTs) support the use of fluoxetine for the treatment of childhood and adolescent depression as well as escitalopram in the treatment of adolescent depression. To date, one RCT has demonstrated the effectiveness of sertraline or citalopram for the treatment of major depressive disorder in youth. Only a small number of RCTs for depression have included children, and none of these trials were adequately powered to detect differences in the efficacy of medication between children and adolescents.

Psychopharmacology of depression in children and adolescents

Although much debate continues about the prevalence of depressive disorders in prepubertal children, depression clearly is common in adolescents, increasing rapidly throughout the teen years. All physicians who work with young patients must to be able to recognize and treat these disorders. This article provides a brief overview of depressive disorders in children and adolescence, including their clinical presentation, prevalence, etiology, course, and prognosis. Psychopharmacological treatment options are reviewed in detail, including practical information for medication management including patient education, making the decision to treat with medication, selection of specific medications, strategies for nonresponsive patients, and decisions about stopping medication.

New-generation antidepressants, suicide and depressed adolescents: how should clinicians respond to changing evidence?

The purpose of the present paper was to identify, from the voluminous literature on efficacy and safety in new-generation antidepressants (NGAs) with depressed children and adolescents, practical clinical strategies for acute phase treatment. To this end a pragmatic survey of studies and reviews was undertaken. Meta-analyses of randomized controlled trials of NGAs in depressed children and adolescents have noted a comparative lack of efficacy, and a weak but statistically significant increased risk of self-harm and suicidal thoughts. But NGA prescription rates and youth suicide rates are generally inversely related, and ensuing 'black box' warnings about NGAs, by deterring NGA prescribing, have possibly contributed to rising youth suicide rates. In moderate-severe depression, benefits for fluoxetine and possibly other NGAs demonstrably outweigh risks. NGAs are not present in adolescents who die by suicide. Concern about NGA risks must be balanced against risks of non-treatment. While mild depression entails regular review, psychoeducation, self-care strategies and psychological interventions, NGAs should be administered concurrently with psychological treatments if depression is moderate- to severe, or if mild depression persists. Patients should be warned about off-label status of NGAs in depression, serious side-effects such as 'activation', suicidality, emotional blunting and manic switches, the need for adherence and avoiding abrupt discontinuation. They should be monitored early and regularly. Better evidence is required regarding psychological treatments, clinical course, and clinical practice trends. In moderate-severe depression the risk of suicide if NGAs are not used may outweigh any risk of self-harm associated with them.

Randomised controlled trials of selective serotonin reuptake inhibitors in treating depression in children and adolescents: a systematic review and meta-analysis

To evaluate the efficacy of selective serotonin reuptake inhibitors (SSRIs) in children and adolescents with depressive disorder, the main electronic databases and the reference lists of retrieved articles and reviews were searched up to January 2007. Randomized controlled studies (RCT) were assessed for methodological quality, taking into consideration the specific diagnostic and severity evaluation tools used, and a meta-analysis on the efficacy of SSRIs compared placebo was undertaken. In all, 13 studies were included, covering a total of 2530 children and adolescents. Eleven studies met the criteria for inclusion in the meta-analysis. The pooled odds ratio was 1.57 (95% C.I. 1.29-1.91). Only fluoxetine appeared to offer a moderately significant benefit profile (OR=2.39). All studies differed in diagnostic tools and primary efficacy measures. SSRI treatment, especially with fluoxetine, may be effective on child and adolescent depression. Nevertheless, additional RCTs with sound methodological designs, validated diagnostic instruments, large sample sizes, and consistent outcomes are necessary to determine the role of SSRIs, alone or in combination with psychological interventions in the treatment of depression in children and adolescents.

Practice parameter for the assessment and treatment of children and adolescents with depressive disorders

This practice parameter describes the epidemiology, clinical picture, differential diagnosis, course, risk factors, and pharmacological and psychotherapy treatments of children and adolescents with major depressive or dysthymic disorders. Side effects of the antidepressants, particularly the risk of suicidal ideation and behaviors are discussed. Recommendations regarding the assessment and the acute, continuation, and maintenance treatment of these disorders are based on the existent scientific evidence as well as the current clinical practice.

The complex roles of neurosteroids in depression and anxiety disorders

The role of neurosteroids in neuropsychiatric disorders has been thoroughly investigated in many research studies that have stressed their significant pathophysiological function in neuropsychiatry. In this review, we will focus mainly on the steroids active on the GABA(A) receptors studied in anxiety and depression. The aim is to discuss the controversial results reported in research on anxiety and depressive disorders. We suggest the combined use of biological parameters linked to psychopathological dimensions to make more homogeneous diagnoses and to develop more precise therapies for the treatment of depression and anxiety disorders. We discuss the role of neurosteroids in the pathophysiology and therapy of anxiety and depression. Finally, we consider the possibility of using quantification of mRNA expression of steroidogenic enzymes from peripheral sources in neuropsychiatry.

Treatment-resistant depression in adolescents: recognition and management

Approximately 20% of adolescents experience at least one depressive episode by the time they enter their adult years. For most adolescents, depression, although serious, either remits spontaneously or responds to treatment. For a smaller but significant proportion of adolescents, however, depression can be long-lasting and relatively unresponsive to initial treatment. In this article the authors provide an operational definition of treatment-resistant depression, identify factors associated with treatment nonresponse, describe an approach to the management of treatment-resistant depression, and advance suggestions for promising avenues of research.