Maintenance study for adolescent depression

Deprescribing Antidepressants in Children and Adolescents: A Systematic Review of Discontinuation Approaches, Cross-Titration, and Withdrawal Symptoms

Background: Antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), are commonly used to treat depressive, anxiety, and obsessive-compulsive disorders in youth. Yet, data on discontinuing these medications, withdrawal symptoms, and strategies to switch between them are limited. Methods: We searched PubMed and ClinicalTrials.gov through June 1, 2024, to identify randomized controlled trials assessing antidepressant discontinuation in youth. We summarized pediatric pharmacokinetic data to inform tapering and cross-titration strategies for antidepressants and synthesized these data with reports of antidepressant withdrawal. Results: Our search identified 528 published articles, of which 28 were included. In addition, 19 records were obtained through other methods, with 14 included. The corpus of records included 13 randomized, double-blind, placebo-controlled trials (3026 patients), including SSRIs (K = 10), SNRIs (K = 4), and TCAs (K = 1), ranging from 4 to 35 weeks. Deprescribing antidepressants requires considering clinical status, treatment response, and, in cross-titration cases, the pharmacokinetics and pharmacodynamics of both medications. Antidepressant withdrawal symptoms are related to the pharmacokinetics of the medication, which vary across antidepressants and may include irritability, palpitations, anxiety, nausea, sweating, headaches, insomnia, paresthesia, and dizziness. These symptoms putatively involve changes in serotonin transporter expression and receptor sensitivity, impacting the serotonin, dopamine, and norepinephrine pathways. Conclusions: Although approaches to deprescribing antidepressants in pediatric patients are frequently empirically guided, accumulating data related to the course of relapse and withdrawal symptoms, as well as the pharmacokinetic and pharmacodynamic properties of medications, should inform these approaches. Recommendations within this review support data-informed discussions of deprescribing-including when and how-that are critically important in the clinician-family-patient relationship.

Meta-Analysis: Relapse Prevention Strategies for Depression and Anxiety in Remitted Adolescents and Young Adults

OBJECTIVE

Depression and anxiety cause a high burden of disease and have high relapse rates (39%-72%). This meta-analysis systematically examined effectiveness of relapse prevention strategies on risk of and time to relapse in youth who remitted.

METHOD

PubMed, PsycInfo, Embase, Cochrane, and ERIC databases were searched up to June 15, 2021. Eligible studies compared relapse prevention strategies to control conditions among youth (mean age 13-25 years) who were previously depressed or anxious or with ≥30% improvement in symptoms. Two reviewers independently assessed titles, abstracts, and full texts; extracted study data; and assessed risk of bias and overall strength of evidence. Random-effects models were used to pool results, and mixed-effects models were used for subgroup analyses. Main outcome was relapse rate at last follow-up (PROSPERO ID: CRD42020149326).

RESULTS

Of 10 randomized controlled trials (RCTs) that examined depression, 9 were eligible for analysis: 4 included psychological interventions (n = 370), 3 included antidepressants (n = 80), and 2 included combinations (n = 132). No RCTs for anxiety were identified. Over 6 to 75 months, relapse was half as likely following psychological treatment compared with care as usual conditions (k = 6; odds ratio 0.56, 95% CI 0.31 to 1.00). Sensitivity analyses including only studies with ≥50 participants (k = 3), showed similar results. Over 6 to 12 months, relapse was less likely in youth receiving antidepressants compared with youth receiving pill placebo (k = 3; OR 0.29, 95% CI 0.10 to 0.82). Quality of studies was suboptimal.

CONCLUSION

Relapse prevention strategies for youth depression reduce risk of relapse, although adequately powered, high-quality RCTs are needed. This finding, together with the lack of RCTs on anxiety, underscores the need to examine relapse prevention in youth facing these common mental health conditions.

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.

Pediatric Psychopharmacology for Depressive and Anxiety Disorders

Anxiety and depressive disorders are the most common psychiatric illnesses among children and adolescents. These disorders are associated with impairments in social, family, and educational functioning. This article summarizes the evidence base for psychopharmacologic interventions; the developmental pharmacology of selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs); and pharmacokinetic and pharmacodynamic differences between youths and adults that call for differences in dosage and affect response and tolerability. The authors also review the efficacy and tolerability of SSRIs and SNRIs in children and adolescents with depressive and anxiety disorder diagnoses, as well as data related to duration of therapy and SSRI/SNRI discontinuation in this population. Taken together, the current evidence suggests that SSRIs are the first-line psychopharmacologic intervention for youths with depressive and anxiety disorders, with SNRIs having a more limited role. These medications are safe and well tolerated, although emerging data and developmental pharmacologic concepts may help clinicians to choose from available SSRIs and to improve the efficacy and tolerability of these medications in children and adolescents.

Discontinuation of antidepressants after remission with antidepressant medication in major depressive disorder: a systematic review and meta-analysis

A significant clinical issue encountered after a successful acute major depressive disorder (MDD) treatment is the relapse of depressive symptoms. Although continuing maintenance therapy with antidepressants is generally recommended, there is no established protocol on whether or not it is necessary to prescribe the antidepressant used to achieve remission. In this meta-analysis, the risk of relapse and treatment failure when either continuing with the same drug used to achieved remission or switching to a placebo was assessed in several clinically significant subgroups. The pooled odds ratio (OR) (±95% confidence intervals (CI)) was calculated using a random effects model. Across 40 studies (n = 8890), the relapse rate was significantly lower in the antidepressant group than the placebo group by about 20% (OR = 0.38, CI: 0.33-0.43, p < 0.00001; 20.9% vs 39.7%). The difference in the relapse rate between the antidepressant and placebo groups was greater for tricyclics (25.3%; OR = 0.30, CI: 0.17-0.50, p < 0.00001), SSRIs (21.8%; OR = 0.33, CI: 0.28-0.38, p < 0.00001), and other newer agents (16.0%; OR = 0.44, CI: 0.36-0.54, p < 0.00001) in that order, while the effect size of acceptability was greater for SSRIs than for other antidepressants. A flexible dose schedule (OR = 0.30, CI: 0.23-0.48, p < 0.00001) had a greater effect size than a fixed dose (OR = 0.41, CI: 0.36-0.48, p < 0.00001) in comparison to placebo. Even in studies assigned after continuous treatment for more than 6 months after remission, the continued use of antidepressants had a lower relapse rate than the use of a placebo (OR = 0.40, CI: 0.29-0.55, p < 0.00001; 20.2% vs 37.2%). The difference in relapse rate was similar from a maintenance period of 6 months (OR = 0.41, CI: 0.35-0.48, p < 0.00001; 19.6% vs 37.6%) to over 1 year (OR = 0.35, CI: 0.29-0.41, p < 0.00001; 19.9% vs 39.8%). The all-cause dropout of antidepressant and placebo groups was 43% and 58%, respectively, (OR = 0.47, CI: 0.40-0.55, p < 0.00001). The tolerability rate was ~4% for both groups. The rate of relapse (OR = 0.32, CI: 0.18-0.64, p = 0.0010, 41.0% vs 66.7%) and all-cause dropout among adolescents was higher than in adults. To prevent relapse and treatment failure, maintenance therapy, and careful attention for at least 6 months after remission is recommended. SSRIs are well-balanced agents, and flexible dose adjustments are more effective for relapse prevention.

Primary outcome reporting in adolescent depression clinical trials needs standardization

BACKGROUND

Evidence-based health care is informed by results of randomized clinical trials (RCTs) and their syntheses in meta-analyses. When the trial outcomes measured are not clearly described in trial publications, knowledge synthesis, translation, and decision-making may be impeded. While heterogeneity in outcomes measured in adolescent major depressive disorder (MDD) RCTs has been described, the comprehensiveness of outcome reporting is unknown. This study aimed to assess the reporting of primary outcomes in RCTs evaluating treatments for adolescent MDD.

METHODS

RCTs evaluating treatment interventions in adolescents with a diagnosis of MDD published between 2008 and 2017 specifying a single primary outcome were eligible for outcome reporting assessment. Outcome reporting assessment was done independently in duplicate using a comprehensive checklist of 58 reporting items. Primary outcome information provided in each RCT publication was scored as "fully reported", "partially reported", or "not reported" for each checklist item, as applicable.

RESULTS

Eighteen of 42 identified articles were found to have a discernable single primary outcome and were included for outcome reporting assessment. Most trials (72%) did not fully report on over half of the 58 checklist items. Items describing masking of outcome assessors, timing and frequency of outcome assessment, and outcome analyses were fully reported in over 70% of trials. Items less frequently reported included outcome measurement instrument properties (ranging from 6 to 17%), justification of timing and frequency of outcome assessment (6%), and justification of criteria used for clinically significant differences (17%). The overall comprehensiveness of reporting appeared stable over time.

CONCLUSIONS

Heterogeneous reporting exists in published adolescent MDD RCTs, with frequent omissions of key details about their primary outcomes. These omissions may impair interpretability, replicability, and synthesis of RCTs that inform clinical guidelines and decision-making in this field. Consensus on the minimal criteria for outcome reporting in adolescent MDD RCTs is needed.

Estimating patient-specific treatment advantages in the 'Treatment for Adolescents with Depression Study'

The 'Treatment for Adolescents with Depression Study' (TADS, ClinicalTrials.gov, identifier: NCT00006286) was a cornerstone, randomized controlled trial evaluating the effectiveness of standard treatment options for major depression in adolescents. Whereas previous TADS analyses examined primarily effect modifications of treatment-placebo differences by various patient characteristics, less is known about the modification of inter-treatment differences, and hence, patient characteristics that might guide treatment selection. We sought to fill this gap by estimating patient-specific inter-treatment differences as a function of patients' baseline characteristics. We did so by applying the 'model-based random forest', a recently-introduced machine learning-based method for evaluating effect heterogeneity that allows for the estimation of patient-specific treatment effects as a function of arbitrary baseline characteristics. Treatment conditions were cognitive-behavioural therapy (CBT) alone, fluoxetine (FLX) alone, and the combination of CBT and fluoxetine (COMB). All inter-treatment differences (CBT vs. FLX; CBT vs. COMB; FLX vs. COMB) were evaluated across 23 potential effect modifiers extracted from previous studies. Overall, FLX was superior to CBT, while COMB was superior to both CBT and FLX. Evidence for effect heterogeneity was found for the CBT-FLX difference and the FLX-COMB difference, but not for the CBT-COMB difference. Baseline depression severity modified the CBT-FLX difference; whereas baseline depression severity, patients' treatment expectations, and childhood trauma modified the FLX-COMB difference. All modifications were quantitative rather than qualitative, however, meaning that the differences varied only in magnitude, but not direction. These findings imply that combining CBT with fluoxetine may be superior to either therapy used alone across a broad range of patients.

Short- and Long-Term Antidepressant Clinical Trials for Major Depressive Disorder in Youth: Findings and Concerns

The diagnosis of major depressive disorder (MDD) in U.S. youth is increasing as is the rate of antidepressant medication (ADM) treatment for the disorder. Fluoxetine and escitalopram are FDA approved for the short term and maintenance treatment of MDD in youth. Placebo-controlled short-term ADM trials represent the basis for Food and Drug Administration (FDA) approval. Meta-analyses in 2007 and 2016 revealed that short-term ADM treatment of youth diagnosed with MDD resulted in no meaningful benefit for children and only marginal benefit for adolescents. Placebo substitution trials of ADM short-term responders represent the basis for FDA approval of ADM maintenance treatment. These ADM placebo substitution maintenance trials for youth with MDD are characterized by high dropout rates, a rapid withdrawal that often can follow the switch to placebo, and relapse rates that are not dissimilar from those in the natural course of the disorder. Without the evidence from problematic ADM placebo substitution trials, there is no acceptable support for the inclusion of ADM in maintenance treatment for MDD in youth.

Update on Randomized Placebo-Controlled Trials in the Past Decade for Treatment of Major Depressive Disorder in Child and Adolescent Patients: A Systematic Review

Objectives: Antidepressant treatment for major depressive disorder (MDD) has been a topic of continued interest with a number of placebo randomized-controlled trials (RCTs) being published in the past decade. We review the updated literature since the 2007 Bridge meta-analysis, and reassess safety data looking at signals of treatment-emergent suicidality with the Columbia Suicide Severity Rating Scale (CSSR-S). Methods: PubMed literature review was performed searching for RCTs published since the 2007 article and supplemented with manual search. Results: Findings from seven trials (five industry sponsored, one NIMH funded, and one other) were included in this systematic review, which showed high medication and placebo response rates, with only fluoxetine and escitalopram treatment reaching statistical significance. Fluoxetine was also shown to prevent relapse of MDD with continued treatment with an odds ratio of 3.2 for prevention of relapse compared with placebo. There were no increases in treatment-emergent suicidality associated with antidepressant medication in any trial measuring suicidality systematically using the CSSR-S. Conclusions: Depressed pediatric patients respond similarly in these trials to antidepressant intervention and placebo, with recent studies showing that newer agents did not clearly demonstrate benefit above placebo. The evidence continues to support fluoxetine and escitalopram as first-line treatment and demonstrated effect to prevent relapse. Use of newer rating scales reveals similar rates of treatment-emergent suicidality in patients on antidepressants as placebo, in contrast to increased suicide signal suggested by past research using adverse events data. Antidepressant treatment is generally safe and well tolerated in this age group.

Treating a broader range of depressed adolescents with combined therapy

BACKGROUND

Traditional statistical analyses of clinical trials encompass the central tendency of outcomes and, hence, are restricted to a treatment's average effectiveness. Our aim was to get a more complete picture of the effectiveness of standard treatment options for adolescent depression, by analyzing treatment effects across low, middle, and high levels of response.

METHODS

Secondary data analysis was performed of the Treatment for Adolescents with Depression Study (TADS, ClinicalTrials.gov, NCT00006286), a randomized controlled trial comparing fluoxetine (FLX), cognitive-behavioral therapy (CBT), and their combination (COMB) against placebo treating adolescents with major depression (n = 439). The proportional change from baseline to week 12 in the Children's Depression Rating Scale-Revised was used as an index of response. Response levels were analyzed via quantile regression models, thereby estimating treatment effects across the entire response level distribution, adjusted for baseline depression, study site, and patients' treatment expectancies.

RESULTS

Whereas CBT was no more effective than placebo across response levels, COMB was more effective than FLX in that its quantile treatment effects were both larger in magnitude and spread out across a broader range of response levels, including the low end of the response level distribution. Cohen's d of the difference was 1.39 (95% confidence interval 1.33-1.45).

LIMITATIONS

Ad-hoc analysis using data from a trial that was not originally designed to accommodate such analysis.

CONCLUSION

The combination of cognitive-behavioral therapy and fluoxetine was more effective than either treatment used alone, not just in average effectiveness, but in the breadth of patients in whom it was effective.

Moderated online social therapy for depression relapse prevention in young people: pilot study of a 'next generation' online intervention

AIM

Implementation of targeted e-mental health interventions offers a promising solution to reducing the burden of disease associated with youth depression. A single-group pilot study was conducted to evaluate the acceptability, feasibility, usability and safety of a novel, moderated online social therapy intervention (entitled Rebound) for depression relapse prevention in young people.

METHODS

Participants were 42 young people (15-25 years) (50% men; mean age = 18.5 years) in partial or full remission. Participants had access to the Rebound platform for at least 12 weeks, including the social networking, peer and clinical moderator and therapy components.

RESULTS

Follow-up data were available for 39 (92.9%) participants. There was high system usage, with 3034 user logins (mean = 72.2 per user) and 2146 posts (mean = 51.1). Almost 70% of users had ≥10 logins over the 12 weeks, with 78.5% logging in over at least 2 months of the pilot. A total of 32 (84%) participants rated the intervention as helpful. There was significant improvement between the number of participants in full remission at baseline (n = 5; none of whom relapsed) relative to n = 19 at 12-week follow-up (P < 0.001). Six (14.3%) participants relapsed to full threshold symptoms at 12 weeks. There was a significant improvement to interviewer-rated depression scores (Montgomery-Asberg Depression Rating Scale (MADRS); P = 0.014, d = 0.45) and a trend for improved strength use (P = 0.088, d = 0.29). The single-group design and 12-week treatment phase preclude a full understanding of the clinical benefits of the Rebound intervention.

CONCLUSIONS

The Rebound intervention was shown to be acceptable, feasible, highly usable and safe in young people with major depression.

Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management

OBJECTIVES

To update clinical practice guidelines to assist primary care (PC) in the screening and assessment of depression. In this second part of the updated guidelines, we address treatment and ongoing management of adolescent depression in the PC setting.

METHODS

By using a combination of evidence- and consensus-based methodologies, the guidelines were updated in 2 phases as informed by (1) current scientific evidence (published and unpublished) and (2) revision and iteration among the steering committee, including youth and families with lived experience.

RESULTS

These updated guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in PC, including (1) active monitoring of mildly depressed youth, (2) treatment with evidence-based medication and psychotherapeutic approaches in cases of moderate and/or severe depression, (3) close monitoring of side effects, (4) consultation and comanagement of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and the grade of its evidence base are summarized.

CONCLUSIONS

The Guidelines for Adolescent Depression in Primary Care cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist PC clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of depressed youth in PC is needed, including the usability, feasibility, and sustainability of guidelines, and determination of the extent to which the guidelines actually improve outcomes of depressed youth.

Antidepressant Treatment Duration in Pediatric Depressive and Anxiety Disorders: How Long is Long Enough?

Anxiety and depressive disorders are common in the pediatric primary care setting, and respond to both psychotherapeutic and psychopharmacologic treatment. However, there are limited data regarding the optimal treatment duration. This article systematically reviews guidelines and clinical trial data related to antidepressant treatment duration in pediatric patients with depressive and anxiety disorders. The extant literature suggests 9-12 months of antidepressant treatment for youth with major depressive disorder. For generalized, separation and social anxiety disorders, 6-9 months of antidepressant treatment may be sufficient, though many clinicians extend treatment to 12 months based on extrapolation of data from adults with anxiety disorders. Such extended treatment periods may decrease the risk of long-term morbidity and recurrence; however, the goal of treatment is ultimately remission, rather than duration of antidepressant pharmacotherapy. Moreover, while evidence-based guidelines represent a starting point, appropriate treatment duration varies and patient-specific response, psychological factors, and timing of discontinuation must be considered for individual pediatric patients.

Theoretical Approaches to Enhancing Motivation for Adherence to Antidepressant Medications

PROBLEM

Adherence to antidepressants is a major challenge in our health care system, with a high percentage of patients discontinuing their medications within six months.

AIMS

The purpose of this position paper is to discuss theoretical frameworks that address the psychological beliefs, benefits and barriers and feelings of autonomy that affect a person's willingness and motivation to take anti-depressant medications within a therapeutic relationship with a nurse practitioner.

METHODS

Three theoretical frameworks were selected to highlight particular perspectives relevant to enhancing patient motivation for medication adherence. The Self-Regulation Model, Health Belief Model, and Self-Determination Theory combined with motivational interviewing all offer guidance on strategies for improving adherence to antidepressants.

CONCLUSIONS

The Self-Regulation Model underscores the importance of illness representations that prompt considering patient perceptions of depression that affect adherence. The Health Belief Model focuses on cost-benefit considerations that affect patient's adherence, along with perceived control. Finally, Self-Determination Theory combined with motivational interviewing offers strategies that enhance autonomy and optimize collaboration and motivation for adherence.

RELEVANCE FOR CLINICAL PRACTICE

These three theoretical models are applied to a vignette for a patient who is having difficulty with adherence to antidepressant medication.

Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder

BACKGROUND

It is unclear whether antidepressants can prevent suicides or suicide attempts, particularly during long-term use.

METHODS

We carried out a comprehensive review of long-term studies of antidepressants (relapse prevention). Sources were obtained from 5 review articles and by searches of MEDLINE, PubMed Central and a hand search of bibliographies. We meta-analyzed placebo-controlled antidepressant RCTs of at least 3 months' duration and calculated suicide and suicide attempt incidence rates, incidence rate ratios and Peto odds ratios (ORs).

RESULTS

Out of 807 studies screened 29 were included, covering 6,934 patients (5,529 patient-years). In total, 1.45 suicides and 2.76 suicide attempts per 1,000 patient-years were reported. Seven out of 8 suicides and 13 out of 14 suicide attempts occurred in antidepressant arms, resulting in incidence rate ratios of 5.03 (0.78-114.1; p = 0.102) for suicides and of 9.02 (1.58-193.6; p = 0.007) for suicide attempts. Peto ORs were 2.6 (0.6-11.2; nonsignificant) and 3.4 (1.1-11.0; p = 0.04), respectively. Dropouts due to unknown reasons were similar in the antidepressant and placebo arms (9.6 vs. 9.9%). The majority of suicides and suicide attempts originated from 1 study, accounting for a fifth of all patient-years in this meta-analysis. Leaving out this study resulted in a nonsignificant incidence rate ratio for suicide attempts of 3.83 (0.53-91.01).

CONCLUSIONS

Therapists should be aware of the lack of proof from RCTs that antidepressants prevent suicides and suicide attempts. We cannot conclude with certainty whether antidepressants increase the risk for suicide or suicide attempts. Researchers must report all suicides and suicide attempts in RCTs.

Continued Effectiveness of Relapse Prevention Cognitive-Behavioral Therapy Following Fluoxetine Treatment in Youth With Major Depressive Disorder

OBJECTIVE

To evaluate the continued effect of a sequential treatment strategy (fluoxetine followed by continued medication plus relapse prevention cognitive-behavioral therapy [RP-CBT]) on relapse prevention beyond the treatment phase.

METHOD

Youth (aged 8-17 years) with major depressive disorder (MDD) were treated with fluoxetine for 6 weeks. Responders (≥50% reduction on the Children's Depression Rating Scale-Revised [CDRS-R]) were randomized to continued medication management alone (MM) or continued medication management plus RP-CBT (MM+CBT) for an additional 6 months. Long-term follow-up assessments were conducted at weeks 52 and 78.

RESULTS

Of 144 youth randomized to MM (n = 69) or MM+CBT (n = 75), 67% had at least 1 follow-up assessment, with equal rates in the 2 groups. Remission rates were high, although most had remitted during the 30-week treatment period. Only 6 additional participants remitted during long-term follow-up, and there were no differences on time to remission between MM+CBT and MM. The MM+CBT group had a significantly lower risk of relapse than the MM group throughout the 78-week follow-up period (hazard ratio = 0.467, 95% CI = 0.264 to 0.823; χ(2) = 6.852, p = .009). The estimated probability of relapse during the 78-week period was lower with MM+CBT than MM only (36% versus 62%). Mean time to relapse was also significantly longer with MM+CBT compared to MM alone by approximately 3 months (p = .007).

CONCLUSION

The addition of RP-CBT after acute response to medication management had a continued effect on reducing risk of relapse even after the end of treatment. Clinical trial registration information-Sequential Treatment of Pediatric MDD to Increase Remission and Prevent Relapse; http://clinicaltrials.gov/; NCT00612313.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. part 2: maintenance treatment of major depressive disorder-update 2015

These guidelines for the treatment of unipolar depressive disorders systematically review available evidence pertaining to the biological treatment of patients with major depression and produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians assessing and treating patients with these conditions. The relevant data have been extracted primarily from various treatment guidelines and panels for depressive disorders, as well as from meta-analyses/reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into five levels of evidence (CE A-F) and five levels of recommendation grades (RG 1-5). This second part of the WFSBP guidelines on depressive disorders covers the management of the maintenance phase treatment, and is primarily concerned with the biological treatment (including pharmacological and hormonal medications, electroconvulsive therapy and other brain stimulation treatments) of adults and also, albeit to a lesser extent, children, adolescents and older adults.

Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents

BACKGROUND

Depressive disorders are common in children and adolescents and, if left untreated, are likely to recur in adulthood. Depression is highly debilitating, affecting psychosocial, family and academic functioning.

OBJECTIVES

To evaluate the effectiveness of psychological therapies and antidepressant medication, alone and in combination, for the treatment of depressive disorder in children and adolescents. We have examined clinical outcomes including remission, clinician and self reported depression measures, and suicide-related outcomes.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to 11 June 2014. The register contains reports of relevant randomised controlled trials (RCTs) from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

RCTs were eligible for inclusion if they compared i) any psychological therapy with any antidepressant medication, or ii) a combination of psychological therapy and antidepressant medication with a psychological therapy alone, or an antidepressant medication alone, or iii) a combination of psychological therapy and antidepressant medication with a placebo or'treatment as usual', or (iv) a combination of psychological therapy and antidepressant medication with a psychological therapy or antidepressant medication plus a placebo.We included studies if they involved participants aged between 6 and 18 years, diagnosed by a clinician as having Major Depressive Disorder (MDD) based on Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the quality of the studies. We applied a random-effects meta-analysis, using the odds ratio (OR) to describe dichotomous outcomes, mean difference (MD) to describe continuous outcomes when the same measures were used, and standard mean difference (SMD) when outcomes were measured on different scales.

MAIN RESULTS

We included eleven studies, involving 1307 participants in this review. We also identified one ongoing study, and two additional ongoing studies that may be eligible for inclusion. Studies recruited participants with different severities of disorder and with a variety of comorbid disorders, including anxiety and substance use disorder, therefore limiting the comparability of the results. Regarding the risk of bias in studies, just under half the studies had adequate allocation concealment (there was insufficient information to determine allocation concealment in the remainder), outcome assessors were blind to the participants' intervention in six studies, and in general, studies reported on incomplete data analysis methods, mainly using intention-to-treat (ITT) analyses. For the majority of outcomes there were no statistically significant differences between the interventions compared. There was limited evidence (based on two studies involving 220 participants) that antidepressant medication was more effective than psychotherapy on measures of clinician defined remission immediately post-intervention (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.27 to 0.98), with 67.8% of participants in the medication group and 53.7% in the psychotherapy group rated as being in remission. There was limited evidence (based on three studies involving 378 participants) that combination therapy was more effective than antidepressant medication alone in achieving higher remission from a depressive episode immediately post-intervention (OR 1.56, 95% CI 0.98 to 2.47), with 65.9% of participants treated with combination therapy and 57.8% of participants treated with medication, rated as being in remission. There was no evidence to suggest that combination therapy was more effective than psychological therapy alone, based on clinician rated remission immediately post-intervention (OR 1.82, 95% CI 0.38 to 8.68).Suicide-related Serious Adverse Events (SAEs) were reported in various ways across studies and could not be combined in meta-analyses. However, some trials measured suicidal ideation using standardised assessment tools suitable for meta-analysis. In one study involving 188 participants, rates of suicidal ideation were significantly higher in the antidepressant medication group (18.6%) compared with the psychological therapy group (5.4%) (OR 0.26, 95% CI 0.09 to 0.72) and this effect appeared to remain at six to nine months (OR 0.26, 95% CI 0.07 to 0.98), with 13.6% of participants in the medication group and 3.9% of participants in the psychological therapy group reporting suicidal ideation. It was unclear what the effect of combination therapy was compared with either antidepressant medication alone or psychological therapy alone on rates of suicidal ideation. The impact of any of the assigned treatment packages on drop out was also mostly unclear across the various comparisons in the review.Limited data and conflicting results based on other outcome measures make it difficult to draw conclusions regarding the effectiveness of any specific intervention based on these outcomes.

AUTHORS' CONCLUSIONS

There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered RCTs are required.

When do you prescribe antidepressants to depressed children?

Major depressive disorder (MDD) in children and adolescents is a public health problem that requires evidence-based management. Our objective is to review available studies, with a PubMed search, and briefly summarize safety and efficacy results of (mostly SSRI) antidepressants in children and adolescents with MDD. Fluoxetine and escitalopram are safe and effective in the treatment of MDD in children and adolescents both in reduction of symptoms, and in remission/response rates. However, response rates are lower than for non-OCD anxiety. Sertraline also had positive results in one study that pooled results from two studies. The number needed to treat (NNT) for MDD is 10, and the number needed to harm (NNH) for suicidality is 112. Methodological limitations in the studies include, mainly, high placebo response rates, associated with multiple study sites, younger patients, and lower MDD severity. Treatment should be maintained close to 1 year after remission, to prevent relapse. FDA-approved fluoxetine and escitalopram are safe and effective in the treatment of pediatric MDD. Sertraline also has some data supporting its efficacy and safety, but is not FDA-approved. The possible modest increase in suicidal ideation in some patients should be known by clinicians, but the risk/benefit ratio is 1 to 11.2 times favorable to using SSRIs in moderate to severe MDD.

Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents

BACKGROUND

Depressive disorders are common in children and adolescents and, if left untreated, are likely to recur in adulthood. Depression is highly debilitating, affecting psychosocial, family and academic functioning.

OBJECTIVES

To evaluate the effectiveness of psychological therapies and antidepressant medication, alone and in combination, for the treatment of depressive disorder in children and adolescents. We have examined clinical outcomes including remission, clinician and self reported depression measures, and suicide-related outcomes.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to 11 November 2011. This register contains reports of relevant randomised controlled trials (RCTs) from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

RCTs were eligible for inclusion if they compared i) any psychological therapy with any antidepressant medication, or ii) a combination of psychological therapy and antidepressant medication with a psychological therapy alone, or an antidepressant medication alone, or iii) a combination of psychological therapy and antidepressant medication with a placebo or 'treatment as usual', or (iv) a combination of psychological therapy and antidepressant medication with a psychological therapy or antidepressant medication plus a placebo.We included studies if they involved participants aged between 6 and 18 years, diagnosed by a clinician as having Major Depressive Disorder (MDD) based on Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the quality of the studies. We applied a random-effects meta-analysis, using the odds ratio (OR) to describe dichotomous outcomes, mean difference (MD) to describe continuous outcomes when the same measures were used, and standard mean difference (SMD) when outcomes were measured on different scales.

MAIN RESULTS

We included ten studies, involving 1235 participants in this review. Studies recruited participants with different severities of disorder and with a variety of comorbid disorders, including anxiety and substance use disorder, therefore limiting the comparability of the results. Regarding the risk of bias in studies, half the studies had adequate allocation concealment (there was insufficient information to determine allocation concealment in the remainder), outcome assessors were blind to the participants' intervention in six studies, and in general, studies reported on incomplete data analysis methods, mainly using intention-to-treat (ITT) analyses. For the majority of outcomes there were no statistically significant differences between the interventions compared. There was limited evidence (based on two studies involving 220 participants) that antidepressant medication was more effective than psychotherapy on measures of clinician defined remission immediately post-intervention (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.27 to 0.98), with 67.8% of participants in the medication group and 53.7% in the psychotherapy group rated as being in remission. There was limited evidence (based on three studies involving 378 participants) that combination therapy was more effective than antidepressant medication alone in achieving higher remission from a depressive episode immediately post-intervention (OR 1.56, 95% CI 0.98 to 2.47), with 65.9% of participants treated with combination therapy and 57.8% of participants treated with medication, rated as being in remission. There was no evidence to suggest that combination therapy was more effective than psychological therapy alone, based on clinician rated remission immediately post-intervention (OR 1.82, 95% CI 0.38 to 8.68).Suicide-related Serious Adverse Events (SAEs) were reported in various ways across studies and could not be combined in meta-analyses. However suicidal ideation specifically was generally measured and reported using standardised assessment tools suitable for meta-analysis. In one study involving 188 participants, rates of suicidal ideation were significantly higher in the antidepressant medication group (18.6%) compared with the psychological therapy group (5.4%) (OR 0.26, 95% CI 0.09 to 0.72) and this effect appeared to remain at six to nine months (OR 1.27, 95% CI 0.68 to 2.36), with 13.6% of participants in the medication group and 3.9% of participants in the psychological therapy group reporting suicidal ideation. It was unclear what the effect of combination therapy was compared with either antidepressant medication alone or psychological therapy alone on rates of suicidal ideation. The impact of any of the assigned treatment packages on drop out was also mostly unclear across the various comparisons in the review.Limited data and conflicting results based on other outcome measures make it difficult to draw conclusions regarding the effectiveness of any specific intervention based on these outcomes.

AUTHORS' CONCLUSIONS

There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered RCTs are required.

Interventions for preventing relapse and recurrence of a depressive disorder in children and adolescents

BACKGROUND

Depressive disorders often begin during childhood or adolescence. There is a growing body of evidence supporting effective treatments during the acute phase of a depressive disorder. However, little is known about treatments for preventing relapse or recurrence of depression once an individual has achieved remission or recovery from their symptoms.

OBJECTIVES

To determine the efficacy of early interventions, including psychological and pharmacological interventions, to prevent relapse or recurrence of depressive disorders in children and adolescents.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 1 June 2011). The CCDANCTR contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). In addition we handsearched the references of all included studies and review articles.

SELECTION CRITERIA

Randomised controlled trials using a psychological or pharmacological intervention, with the aim of preventing relapse or recurrence from an episode of major depressive disorder (MDD) or dysthymic disorder (DD) in children and adolescents were included. Participants were required to have been diagnosed with MDD or DD according to DSM or ICD criteria, using a standardised and validated assessment tool.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials for inclusion in the review, extracted trial and outcome data, and assessed trial quality. Results for dichotomous outcomes are expressed as odds ratio and continuous measures as mean difference or standardised mean difference. We combined results using random-effects meta-analyses, with 95% confidence intervals. We contacted lead authors of included trials and requested additional data where possible.

MAIN RESULTS

Nine trials with 882 participants were included in the review. In five trials the outcome assessors were blind to the participants' intervention condition and in the remainder of trials it was unclear. In the majority of trials, participants were either not blind to their intervention condition, or it was unclear whether they were or not. Allocation concealment was also unclear in the majority of trials. Although all trials treated participants in an outpatient setting, the designs implemented in trials was diverse, which limits the generalisability of the results. Three trials indicated participants treated with antidepressant medication had lower relapse-recurrence rates (40.9%) compared to those treated with placebo (66.6%) during a relapse prevention phase (odds ratio (OR) 0.34; 95% confidence interval (CI) 0.18 to 0.64, P = 0.02). One trial that compared a combination of psychological therapy and medication to medication alone favoured a combination approach over medication alone, however this result did not reach statistical significance (OR 0.26; 95% CI 0.06 to 1.15). The majority of trials that involved antidepressant medication reported adverse events including suicide-related behaviours. However, there were not enough data to show which treatment approach results in the most favourable adverse event profile.

AUTHORS' CONCLUSIONS

Currently, there is little evidence to conclude which type of treatment approach is most effective in preventing relapse or recurrence of depressive episodes in children and adolescents. Limited trials found that antidepressant medication reduces the chance of relapse-recurrence in the future, however, there is considerable diversity in the design of trials, making it difficult to compare outcomes across studies. Some of the research involving psychological therapies is encouraging, however at present more trials with larger sample sizes need to be conducted in order to explore this treatment approach further.

Depression

This article reviews the assessment and treatment for depression in children and adolescents, emphasizing the implementation of evidence-based treatments into clinical care. Past trials of antidepressant medications are reviewed, as well as the clinical use of antidepressants and pharmacologic strategies for refractory illness or in the context of comorbid conditions. Clinicians who treat youth now have a body of empiric research to help guide treatment decisions; however, personalized treatment based on associated symptoms, comorbid conditions, contextual factors, and psychiatric history is essential. Further research is needed in the pharmacologic treatment of depressed youth, including expanding the study of non-SSRI antidepressants, augmentation and adjunctive strategies, and treatment in patients with comorbid conditions.

Blue again: perturbational effects of antidepressants suggest monoaminergic homeostasis in major depression

Some evolutionary researchers have argued that current diagnostic criteria for major depressive disorder (MDD) may not accurately distinguish true instances of disorder from a normal, adaptive stress response. According to disorder advocates, neurochemicals like the monoamine neurotransmitters (serotonin, norepinephrine, and dopamine) are dysregulated in major depression. Monoamines are normally under homeostatic control, so the monoamine disorder hypothesis implies a breakdown in homeostatic mechanisms. In contrast, adaptationist hypotheses propose that homeostatic mechanisms are properly functioning in most patients meeting current criteria for MDD. If the homeostatic mechanisms regulating monoamines are functioning properly in these patients, then oppositional tolerance should develop with prolonged antidepressant medication (ADM) therapy. Oppositional tolerance refers to the forces that develop when a homeostatic mechanism has been subject to prolonged pharmacological perturbation that attempt to bring the system back to equilibrium. When pharmacological intervention is discontinued, the oppositional forces cause monoamine levels to overshoot their equilibrium levels. Since depressive symptoms are under monoaminergic control, this overshoot should cause a resurgence of depressive symptoms that is proportional to the perturbational effect of the ADM. We test this prediction by conducting a meta-analysis of ADM discontinuation studies. We find that the risk of relapse after ADM discontinuation is positively associated with the degree to which ADMs enhance serotonin and norepinephrine in prefrontal cortex, after controlling for covariates. The results are consistent with oppositional tolerance, and provide no evidence of malfunction in the monoaminergic regulatory mechanisms in patients meeting current diagnostic criteria for MDD. We discuss the evolutionary and clinical implications of our findings.

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.