The treatment of adolescent depression in the era of the black box warning

Systematic Review and Meta-Analysis: The Association Between Newer-Generation Antidepressants and Insomnia in Children and Adolescents With Major Depressive Disorder

OBJECTIVE

To examine the association between newer generation antidepressants and insomnia as an adverse event (AE) in the treatment of children and adolescents with major depressive disorder (MDD).

METHOD

A systematic search was performed in major databases (inception to August 31, 2023) to retrieve double-blind, placebo-controlled, randomized controlled trials (RCTs) evaluating the safety of 19 antidepressants in the acute treatment (initial 6-12 weeks) of children and adolescents ≤18 years of age with MDD (primary analyses). RCTs in anxiety disorders and obsessive-compulsive disorder (OCD) were retrieved from a recent meta-analysis and included in complementary analyses. A mixed-effects logistic regression model was used to compare the frequency of insomnia in the antidepressant relative to the placebo group. Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool.

RESULTS

In total, 20 trials in MDD (N = 5,357) and 8 trials in anxiety disorders and OCD (N = 1,271) evaluating selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) were included. In MDD, antidepressant treatment was associated with a modest increase in the odds of insomnia compared with placebo (odds ratio [OR] = 1.65, 95% CI = 1.21-2.27, p = .002), with no significant difference between SSRIs and SNRIs. The RCTs showed low risk of bias or minor concerns for the assessment of insomnia. The odds of treatment-emergent insomnia were significantly lower in MDD (OR = 1.62; 95% CI = 1.21-2.15) compared to anxiety disorders and OCD (OR = 2.89; 95% CI = 1.83-4.57) for treatment with SSRIs (p = .03). Among individual antidepressants with evidence from ≥3 studies, sertraline had the highest OR (3.45; 95% CI = 1.91-6.24), whereas duloxetine had the lowest OR (1.38; 95% CI = 0.79-2.43).

CONCLUSION

Children and adolescents are at a modestly increased risk for experiencing insomnia during the first 6 to 12 weeks of treatment with SSRIs and SNRIs. Antidepressant- and disorder-specific variability in the risk of treatment-emergent insomnia may be relevant to consider in clinical decision making.

STUDY PREREGISTRATION INFORMATION

The association between newer generation antidepressants and insomnia in children and adolescents with major depressive disorder: a meta-analysis of randomized controlled trials; https://www.crd.york.ac.uk; CRD42023330506.

The Resilient Phenotype Induced by Prophylactic Ketamine Exposure During Adolescence Is Mediated by the Ventral Tegmental Area-Nucleus Accumbens Pathway

BACKGROUND

Major depressive disorder is prevalent in children and adolescents and is associated with a high degree of morbidity throughout life, with potentially devastating personal consequences and public health impact. The efficacy of ketamine (KET) as an antidepressant has been demonstrated in adolescent rodents; however, the neurobiological mechanisms underlying these effects are unknown. Recent evidence showed that KET reverses stress-induced (i.e., depressive-like) deficits within major mesocorticolimbic regions, such as the prefrontal cortex, nucleus accumbens (NAc), and hippocampus, in adult rodents. However, little is known about KET's effect in the ventral tegmental area (VTA), which provides the majority of dopaminergic input to these brain regions.

METHODS

We characterized behavioral, biochemical, and electrophysiological effects produced by KET treatment in C57BL/6J male mice during adolescence (n = 7-10 per condition) within the VTA and its major projection regions, namely, the NAc and prefrontal cortex. Subsequently, molecular targets within the VTA-NAc projection were identified for viral gene transfer manipulations to recapitulate the effects of stress or KET treatment.

RESULTS

Repeated KET treatment produced a robust proresilient response to chronic social defeat stress. This effect was largely driven by Akt signaling activity within the VTA and NAc, and it could be blocked or recapitulated through direct Akt-viral-mediated manipulation. Additionally, we found that the KET-induced resilient phenotype is dependent on VTA-NAc, but not VTA-prefrontal cortex, pathway activity.

CONCLUSIONS

These findings indicate that KET exposure during adolescence produces a proresilient phenotype mediated by changes in Akt intracellular signaling and altered neuronal activity within the VTA-NAc pathway.

Effectiveness of usual-care cognitive-behavioral therapy for adolescents with depressive disorders rated by parents and patients - an observational study

BACKGROUND

Depressive disorders are common in adolescence and are associated with a wide range of negative long-term outcomes. Highly controlled randomized controlled trials (RCT) provide considerable evidence for the efficacy of cognitive-behavioral therapy (CBT) as a treatment for depression, but studies examining the effectiveness of CBT in clinical settings are very rare .

METHODS

In the present observational study, the changes achieved through routine CBT in adolescents with depressive disorders treated in a clinical setting in terms of a university outpatient clinic were analyzed, and compared to a historical control group of adolescents with depressive disorders who had received treatment as usual. At the start and end of treatment (pre- and post-assessment), parent and self-ratings of the German versions of the Youth Self-Report (YSR), the Child Behavior Checklist (CBCL) and rating scales for depressive symptoms (FBB-DES, SBB-DES) were assessed. A total of 331 adolescents aged 11-18 years with complete data were assessed for the main analysis.

RESULTS

The analysis yielded small to large pre-post effect sizes (Cohen's d) for the total sample (d = 0.33 to d = 0.82) and large effect sizes for adolescents who were rated in the clinical range on each (sub) scale at the start of treatment (d = 0.85 to d = 1.30). When comparing patients in the clinical range with historical controls, medium to large net effect sizes (d = 0.53 to d = 2.09) emerged for the total scores in self- and parent rating. However, a substantial proportion of the sample remained in the clinical range at the end of treatment.

CONCLUSIONS

These findings suggest that CBT is effective for adolescents with depressive disorders when administered under routine care conditions, but the results must be interpreted with caution due to the lack of a direct control condition.

TRIAL REGISTRATION

DRKS, DRKS00021518 . Registered 27 April 2020 - Retrospectively registered, http://drks.de.

[Evaluation of Short-term Psychoanalytic Child Therapy (PaCT) for Young Children with Depressive Disorders: Results from a Pilot Study]

Depressive disorders in early childhood are associated with high psychosocial impairment and tend to remain stable over time without adequate treatment. Short-term psychoanalytic therapy is a common form of child psychotherapy, yet there is a lack of empirical evaluation of this approach for young children with depressive disorders. Therefore, this secondary evaluation of a study on the treatment of anxiety disorders used an uncontrolled pre-post design in a clinical setting to investigate whether children with depressive comorbidity would evidence significant diagnostic and symptomatic remission after treatment with manualized short-term Psychoanalytic Child Therapy (PaCT). Nineteen children who had an anxiety disorder and a (subclinical) depressive disorder (assessed with the Preschool Age Psychiatric Assessment using DSM-IV criteria) were treated with PaCT. After treatment, 15 of 19 children (78.94 %) were remitted and 15 of 17 children (88.24 %; 2 were lost to follow-up) were free of depressive disorders at the 6-month follow-up. Further analyses revealed significant effects for pre- to post and pre- to follow-up comparisons regarding internalizing symptoms and overall problems using parent- and (nursery-)teacher-ratings. These results suggest that short-term PaCT shows promise as a treatment for childhood depressive disorders.

Psychiatric Diseases in Children and Adolescents

Pharmacotherapy of psychiatric illnesses in children and adolescents has grown significantly over the last few decades. However, the body of research examining pharmacological treatments for psychiatric illnesses is much smaller in children and adolescents than it is in adults. As most treatments for psychiatric disorders are more effective if started early in the course of illness, treatment options for youth are especially important in order to ensure better treatment outcomes. This chapter discusses currently approved medications to treat psychiatric disorders in children and adolescents. Research on medications that may be effective treatments but are not yet FDA approved is also discussed. The medications are broken down into major categories used in youth with psychiatric disorders including antidepressants, mood stabilizers, ADHD medications, and antipsychotics.

Treatment of Major Depressive Disorder in Pediatric Populations

Major depressive disorder (MDD) is a severe illness that afflicts about 16.6% of people over their lifetime. MDD is highly correlated with suicidality, and often first presents in adolescence. Unfortunately, many pediatric patients suffering from MDD go undiagnosed, and current evidence-based treatment options in the U.S. are limited to psychotherapy and two selective serotonin reuptake inhibitors approved by the United States Food and Drug Administration. Molecular mechanisms have been shown to play a role in MDD pathogenesis, progression, and response to medication, yet few studies have explored the role of these pathways in pediatric MDD. In this review, we outline the gravity and importance of MDD in pediatric patients, some challenges in diagnosis and treatment, current treatments available for pediatric patients, and research to investigate differences between pediatric and adult MDD. We hope that this review will provide an outline of the current understanding and treatment of MDD in pediatric patients, and provide thoughtful insights for future work that could advance our understanding of MDD in pediatric populations, and also identify new therapeutic strategies.

Comparing Two Models of Integrated Behavioral Health Programs in Pediatric Primary Care

This study examined how to design, staff, and evaluate the feasibility of 2 different models of integrated behavioral health programs in pediatric primary care across primary care sites in the Bronx, NY. Results suggest that the Behavioral Health Integration Program model of pediatric integrated care is feasible and that hiring behavioral health staff with specific training in pediatric, evidence-informed behavioral health treatments may be a critical variable in increasing outcomes such as referral rates, self-reported competency, and satisfaction.

Fluoxetine exposure during adolescence increases preference for cocaine in adulthood

Currently, there is a high prevalence of antidepressant prescription rates within juvenile populations, yet little is known about the potential long-lasting consequences of such treatments, particularly on subsequent responses to drugs of abuse. To address this issue at the preclinical level, we examined whether adolescent exposure to fluoxetine (FLX), a selective serotonin reuptake inhibitor, results in changes to the sensitivity of the rewarding properties of cocaine in adulthood. Separate groups of male c57bl/6 mice were exposed to FLX (0 or 20 mg/kg) for 15 consecutive days either during adolescence (postnatal days [PD] 35–49) or adulthood (PD 65–79). Twenty-one days after FLX treatment, behavioral responsivity to cocaine (0, 2.5, 5, 10, or 20 mg/kg) conditioned place preference was assessed. Our data shows that mice pretreated with FLX during adolescence, but not during adulthood, display an enhanced dose-dependent preference to the environment paired with cocaine (5 or 10 mg/kg) when compared to age-matched saline pretreated controls. Taken together, our findings suggest that adolescent exposure to FLX increases sensitivity to the rewarding properties of cocaine, later in life.

Beyond a diagnosis: The experience of depression among clinically-referred adolescents

Policy-makers have identified an urgent need to improve our ability to detect and diagnose depression in adolescents. This study aims to explore the lived experience of depression in clinically referred adolescents. 77 adolescents, aged between 11 and 17 with moderate to severe depression, were interviewed as part of a randomised controlled trial, using the Expectations of Therapy Interview. Data were analysed qualitatively using framework analysis, with a focus on how the adolescents spoke about their depression. The study identified five themes: 1) Misery, despair and tears; 2) Anger and violence towards self and others; 3) A bleak view of everything; 4) Isolation and cutting off from the world; and 5) The impact on education. Researchers and policy-makers need to develop an understanding of depression grounded in the experiences of adolescents to improve detection and diagnosis of depression.

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.

Repeated ketamine exposure induces an enduring resilient phenotype in adolescent and adult rats

BACKGROUND

Major depressive disorder afflicts up to 10% of adolescents. However, nearly 50% of those afflicted are considered nonresponsive to available treatments. Ketamine, a noncompetitive N-methyl-D-aspartate receptor antagonist has shown potential as a rapid-acting and long-lasting treatment for major depressive disorder in adults. Thus, the effectiveness and functional consequences of ketamine exposure during adolescence were explored.

METHODS

Adolescent male rats (postnatal day [PD] 35) received two ketamine (0, 5, 10, or 20 mg/kg) injections, 4 hours apart, after exposure to day 1 of the forced swim test (FST). The next day, rats were reexposed to the FST to assess ketamine-induced antidepressant-like responses. Separate groups were exposed to chronic unpredictable stress to confirm findings from the FST. After these initial experiments, adolescent naive rats were exposed to either 1 or 15 consecutive days (PD35-49) of ketamine (20 mg/kg) twice daily. Ketamine's influence on behavioral reactivity to rewarding (i.e., sucrose preference) and aversive (i.e., elevated plus-maze, FST) circumstances was then assessed 2 months after treatment. To control for age-dependent effects, adult rats (PD75-89) were exposed to identical experimental conditions.

RESULTS

Ketamine (20 mg/kg) reversed the chronic unpredictable stress-induced depression-like behaviors in the FST. Repeated ketamine exposure resulted in anxiolytic- and antidepressant-like responses 2 months after drug exposure. None of the ketamine doses used were capable of inducing drug-seeking behaviors as measured by place preference conditioning.

CONCLUSIONS

Repeated ketamine exposure induces enduring resilient-like responses regardless of age of exposure. These findings point to ketamine, and its repeated exposure, as a potentially useful antidepressant during adolescence.

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.

Newer generation antidepressants for depressive disorders in children and adolescents

BACKGROUND

Depressive disorders are common in young people and are associated with significant negative impacts. Newer generation antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), are often used, however evidence of their effectiveness in children and adolescents is not clear. Furthermore, there have been warnings against their use in this population due to concerns about increased risk of suicidal ideation and behaviour.

OBJECTIVES

To determine the efficacy and adverse outcomes, including definitive suicidal behaviour and suicidal ideation, of newer generation antidepressants compared with placebo in the treatment of depressive disorders in children and adolescents.

SEARCH METHODS

For this update of the review, we searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to October 2011. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: CENTRAL (the Cochrane Central Register of Controlled Trials) (all years), EMBASE (1974 -), MEDLINE (1950 -) and PsycINFO (1967 -). We searched clinical trial registries and pharmaceutical company websites. We checked reference lists of included trials and other reviews, and sent letters to key researchers and the pharmaceutical companies of included trials from January to August 2011.

SELECTION CRITERIA

Published and unpublished randomised controlled trials (RCTs), cross-over trials and cluster trials comparing a newer generation antidepressant with a placebo in children and adolescents aged 6 to 18 years old and diagnosed with a depressive disorder were eligible for inclusion. In this update, we amended the selection criteria to include newer generation antidepressants rather than SSRIs only.

DATA COLLECTION AND ANALYSIS

Two or three review authors selected the trials, assessed their quality, and extracted trial and outcome data. We used a random-effects meta-analysis. We used risk ratio (RR) to summarise dichotomous outcomes and mean difference (MD) to summarise continuous measures.

MAIN RESULTS

Nineteen trials of a range of newer antidepressants compared with placebo, containing 3335 participants, were included. The trials excluded young people at high risk of suicide and many co-morbid conditions and the participants are likely to be less unwell than those seen in clinical practice. We judged none of these trials to be at low risk of bias, with limited information about many aspects of risk of bias, high drop out rates and issues regarding measurement instruments and the clinical usefulness of outcomes, which were often variously defined across trials. Overall, there was evidence that those treated with an antidepressant had lower depression severity scores and higher rates of response/remission than those on placebo. However, the size of these effects was small with a reduction in depression symptoms of 3.51 on a scale from 17 to 113 (14 trials; N = 2490; MD -3.51; 95% confidence interval (CI) -4.55 to -2.47). Remission rates increased from 380 per 1000 to 448 per 1000 for those treated with an antidepressant. There was evidence of an increased risk (58%) of suicide-related outcome for those on antidepressants compared with a placebo (17 trials; N = 3229; RR 1.58; 95% CI 1.02 to 2.45). This equates to an increased risk in a group with a median baseline risk from 25 in 1000 to 40 in 1000. Where rates of adverse events were reported, this was higher for those prescribed an antidepressant. There was no evidence that the magnitude of intervention effects (compared with placebo) were modified by individual drug class.

AUTHORS' CONCLUSIONS

Caution is required in interpreting the results given the methodological limitations of the included trials in terms of internal and external validity. Further, the size and clinical meaningfulness of statistically significant results are uncertain. However, given the risks of untreated depression in terms of completed suicide and impacts on functioning, if a decision to use medication is agreed, then fluoxetine might be the medication of first choice given guideline recommendations. Clinicians need to keep in mind that there is evidence of an increased risk of suicide-related outcomes in those treated with antidepressant medications.

Trends in youth antidepressant dispensing and refill limits, 2000 through 2009

BACKGROUND

Antidepressant (AD) dispensing for depression in youth declined in the years following the 2003-04 Food and Drug Administration actions regarding increased risk of suicidal behavior.

OBJECTIVE

To extend observation of youth AD dispensing and associated characteristics through 2009 to determine if AD dispensing continues to decline, has stabilized, or has rebounded.

DESIGN

Retrospective time series design.

SAMPLE

Youth (n=57,782) ages 10 to 17 inclusive.

RESULTS

Both new (incident) and refill AD dispensing continued to decline through 2009, with no sign of leveling off. However, among youth who started AD treatment the cumulative supply of AD medication remained consistent across the pre- and postperiods, suggesting that cumulative treatment episode duration has not been degraded--possibly as a function of greater days supply with each new refill in the postperiod. Prescribers dramatically curtailed preauthorized refills in the postwarning period.

CONCLUSION

Declines in AD dispensing to depressed youth may not reflect less intensive treatment for those youth who persist beyond the initial dispense. Lower rates of preauthorized refills may have been an attempt by prescribers to encourage return visits to evaluate response and adverse consequences.

Treatment-resistant depression in adolescents: is the addition of cognitive behavioral therapy of benefit?

Background

Many young people with major depression fail first-line treatments. Treatment-resistant depression has various definitions in the literature but typically assumes nonresponse to medication. In young people, cognitive behavioral therapy (CBT) is the recommended first-line intervention, thus the definition of treatment resistance should be expanded. Therefore, our aim was to synthesize the existing evidence of any interventions for treatment-resistant depression, broadly defined, in children and adolescents and to investigate the effectiveness of CBT in this context.

Methods

We used Cochrane Collaboration methodology, with electronic searches of Medline, PsycINFO, Embase, and the Cochrane Depression Anxiety and Neurosis Group trials registers. Only randomized controlled trials were included, and were assessed for risk of bias. Meta- analysis was undertaken where possible and appropriate.

Results

Of 953 articles retrieved, four trials were eligible for inclusion. For one study, only the trial registration document was available, because the study was never completed. All other studies were well conducted with a low risk of bias, although one study had a high dropout rate. Two studies assessed the effect of adding CBT to medication. While an assertive trial of antidepressants does appear to lead to benefit, when compared with placebo, there was no significant advantage, in either study, or in a meta-analysis of data from these trials, that clearly demonstrated an additional benefit of CBT. The third trial showed little advantage of a tricyclic antidepressant over placebo in the context of an inpatient admission.

Conclusion

Few randomized controlled trials have investigated interventions for treatment-resistant depression in young people, and results from these show modest benefit from antidepressants with no additional benefit over medication from CBT. Overall, there is a lack of evidence about effective interventions to treat young people who have failed to respond to evidence-based interventions for depression. Research in this area is urgently required.

Impact of initiation timing of SSRI or SNRI on depressed adolescent healthcare utilization and costs

BACKGROUND

Adolescents with newly diagnosed depression may not receive timely antidepressant therapy. Clinical and economic effects of early versus late treatment initiation are unclear.

OBJECTIVE

To compare effects of early versus late initiation of second-generation (SSRI/SNRI) antidepressants on emergency room (ER) visits, hospitalizations and healthcare costs in adolescents with depression.

METHODS

Patients aged 12-17 with a diagnosis of depression were identified in a claims database (1999-2007). Patients initiating antidepressants within 1 month of initial diagnosis were considered early initiators; patients initiating within 2-12 months were late initiators. Clinical resource use and healthcare costs were measured during the 6-month pre-index and 12-month post-index (study) periods and compared descriptively between groups. Logistic regression compared healthcare services utilization; a generalized linear model compared costs. All models were adjusted for baseline characteristics, including demographics, comorbidities, and healthcare services utilization.

RESULTS

A total of 7344 adolescents met study criteria. 4415 (60%) initiated antidepressant treatment within 1 month of diagnosis. At baseline, early initiators had more all-cause inpatient visits (14 vs. 7%) and all-cause ER visits than late initiators (25 vs. 21%, both p<0.01). They had higher medical ($1434 vs. $1160) and total costs ($1565 vs. $1290) (both p<0.01). In the study period, late initiators had higher risk of ER visits (OR=1.13, p=0.03). They incurred higher medical costs ($5415 vs. $4061) and higher total healthcare costs ($6001 vs. $4907), but lower adjusted drug costs ($767 vs. $888) (all p<0.01).

LIMITATIONS

Clinical data are scarce in the claims database, and the ability to observe disease severity and reasons for delayed treatment is limited. The definition of early and late initiation was based on empirical analysis, and no clear cutoff was identified beyond what was observed in the data.

CONCLUSIONS

Adolescents who initiated SSRI/SNRI therapy earlier experienced lower risk of ER visits and had lower total costs compared to late initiators.

Paroxetine-induced increase in activity of locus coeruleus neurons in adolescent rats: implication of a countertherapeutic effect of an antidepressant

The concern that antidepressant (AD) drugs, especially selective serotonin reuptake inhibitors and paroxetine (PAR) in particular, can increase suicidality during the early treatment of juvenile patients (children and adolescents) has created a dilemma for clinicians treating depressives. Although preclinical research cannot resolve controversy in this area, our present findings may provide insight into how AD drugs might, under certain conditions, exacerbate rather than ameliorate the depressive state. Both clinical and preclinical evidences indicate that the principal noradrenergic cell group in the brain, the locus coeruleus (LC), is overactive in depressives and that, conversely, effective AD treatments decrease the activity of LC neurons. We report here that short-term (2 and 4 days) administration of PAR produces an increase in the activity of LC neurons (spontaneous firing rate and sensory-evoked responses) in young rats, contrary to the 'therapeutic' decrease in activity typically observed in adult rats. Blood levels of PAR were lower in young rats than in adult rats, although similar low blood levels produced by a lower dose of PAR in adult rats failed to produce an increase in LC activity. In addition, activity of young rats in the swim test was determined to assess depressive-like responses. The same dose/durations of PAR, which produced the largest increases in LC activity in young rats, produced decreases in swim-test activity, indicating that brief administration of PAR in young rats can promote, rather than reduce, the depressive state. These results offer a model that may help screen potential adjunctive treatments to avoid early adverse effects of ADs.

Tailoring treatment of depression for women across the reproductive lifecycle: the importance of pregnancy, vasomotor symptoms, and other estrogen-related events in psychopharmacology

Compared with men, women are at increased risk of depression, especially at several reproductive-related lifecycle points. This may be partially due to changing levels of estrogen, a hormone that can affect levels of neurotransmitters and neural proteins. As estrogen levels vary throughout the lifespan, risk of depression in women also varies, and not all treatments are appropriate or effective at all times. In adolescence, onset of depression may be associated with onset of puberty, but treating underage girls with antidepressants can risk suicidality. In females of childbearing age, mood disturbances associated with menstrual cycles signal a risk for later full-blown major depressive disorder. In depressed pregnant and postpartum women, risks of treatment versus risks of nontreatment are intricate and require case-by-case evaluation. In perimenopause, vasomotor symptoms may be harbingers of oncoming depression and also may signal the presence of dysregulated hormones and neurotransmitters. Relieving vasomotor symptoms may be a necessary dimension of treating depression. In postmenopause, response to selected antidepressants may depend on whether the patient is also taking hormone-replacement therapy. To attain optimal outcomes, modern psychopharmacologists must tailor treatment of depression to a woman's reproductive stage of life.

Integrating evidence into clinical information systems for nursing decision support

PURPOSE

To illustrate approaches for providing decision support for evidence-based nursing practice through integration of evidence into clinical information systems (CISs) with examples from our experience at Columbia University Medical Center.

ORGANIZING CONSTRUCT

Examples are organized according to three types of decision support functions: information management, focusing attention, and patient-specific consultation.

METHODS

Three decision support tools that are integrated into three types of CISs are discussed: (1) infobuttons that provide context-specific access to digital sources of evidence; (2) automated Fall-Injury Risk Assessment; and (3) personal digital assistant-based screening reminders, screening assessments, and tailored documentation templates for the identification and management of obesity, depression, and tobacco cessation. The informatics infrastructure for implementing these decision support tools is described from the perspective of components identified in the published literature.

CONCLUSIONS

Efforts to facilitate application of evidence into nursing practice are unlikely to be successful unless the approaches used are integrated into the clinical workflow. Our approaches use a variety of informatics methods to integrate evidence into CISs as a mechanism for providing decision support for evidence-based practice in a manner consistent with nursing workflow.

Risk of adverse behavioral effects with pediatric use of antidepressants

OBJECTIVES

This article reviews evidence that led the Food and Drug Administration to issue a "black box" warning about the risk of "suicidality" (suicidal thoughts and behavior) in children and adolescents during treatment with antidepressants.

RESULTS

Re-analysis of data from randomized clinical trials of antidepressants in the pediatric population revealed a significantly greater overall (all drugs across all indications) risk ratio for drug 1.95 (95% Cl, 1.28-2.98) compared to placebo in this sample of approximately 4,000 subjects.

DISCUSSION

The essential message of the "black box" is to remind prescribers and consumers about the importance of monitoring closely for adverse behavioral changes during the initiation of (or changes in) antidepressant therapy. Possible mechanisms that might account for this phenomenon, particularly the so-called activation syndrome, are discussed.

CONCLUSION

Empirical studies are needed to identify the precursors of suicidality and to predict which individuals are most susceptible to adverse behavioral side effects of antidepressants.

Controversy revisited: Selective serotonin reuptake inhibitors in paediatric depression

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are currently controversial treatments for paediatric depression. There have been several publications on the subject during recent years. This article summarizes their findings and provides some original thoughts, suggestions, and perspectives.

METHODS

Important and relevant articles presenting original data and published in leading journals during 2003-2005 were identified through a PubMed search. Articles instructive in content were selected. A narrative sequence is used to review the field, build arguments, and propound views.

RESULTS

Ten principal and several other auxiliary studies were identified for scrutiny. The findings of these studies suggest that published clinical trials of SSRIs in paediatric depression have overstated the antidepressant benefits and understated the risks of suicidal ideation and behaviour arising with treatment; the unpublished clinical trial data are even more unfavourable. Nevertheless, the clinical, epidemiological, and forensic data do suggest overall safety and efficacy of the SSRIs, amongst which fluoxetine may have the best risk-benefit profile.

CONCLUSIONS

Psychotherapeutic interventions may not always be feasible or effective, especially when depression is more severe. The failure to prescribe a drug may, at the very least, lead to the loss of the placebo effect. It is therefore suggested that, if the diagnosis of unipolar depression is confident, appropriate doses of fluoxetine may be prescribed to depressed children and adolescents; the use of rescue medication to treat emergent agitation is important, and augmentation with psychotherapy may further improve outcomes. The monitoring of indices of growth may also be necessary.

Quality of mental health care for youth with asthma and comorbid anxiety and depression

OBJECTIVES

Youth with asthma have a high rate of anxiety and depressive disorders, and these comorbid disorders are associated with increased asthma symptom burden and functional impairment. This study examined the rates and predictors of recognition of anxiety and depressive disorders among youth (ages 11 to 17) with asthma who are seen in primary care settings as well as the quality of mental health care provided to those with comorbid anxiety and depression over a 12-month period.

METHODS

This study used automated utilization and pharmacy data from a health maintenance organization to describe the rate of recognition of Diagnostic and Statistical Manual of Mental Disorders, edition IV, anxiety and depressive disorders and the quality of mental health care provided for the 17% of youth with asthma and comorbid anxiety and/or depression during the 12-month period prior to diagnosis. Psychiatric diagnoses were based on a telephone version of the Computerized Diagnostic Interview Schedule for Children (Version 4.0).

RESULTS

Approximately 35% of youth with 1 or more anxiety and depressive disorders and 43% of those with major depression were recognized by the medical system during a 12-month period. Greater functional impairment (odds ratio [OR] 3.32, 95% confidence interval [CI] 1.25-8.79), higher severity on parent-rated anxiety and depressive symptoms (OR 2.49, 95% CI 1.04-6.00), and a greater number of primary care visits (OR 1.26, 95% CI 1.10-1.44) were associated with significantly higher recognition rates while having Medicaid or Washington state medical insurance was associated with lower rates of recognition (OR 0.27, 95% CI 0.08-0.92). Only approximately 1 in 5 youths with comorbid major depression received an adequate dosage and duration of antidepressant medication, and only 1 in 6 received a minimally adequate number of psychotherapy sessions (> or =4 visits).

CONCLUSION

Rates of recognition of comorbid anxiety and depressive disorders are low in youth with asthma and few youth with asthma and comorbid anxiety and depression receive guideline-level mental health treatment.

Antidepressants in children and adolescents—changes in utilisation after safety warnings

BACKGROUND

Antidepressants, in particular selective serotonin reuptake inhibitors, are one of the most commonly used classes of psychotropic drug in children and adolescents. Beginning in June 2003, evidence emerged suggesting that antidepressants may increase risk of suicidal behaviour in young people. This evidence was accompanied by national and international guidelines cautioning against use of many antidepressants in young people. This study aimed to assess whether these safety warnings have impacted upon antidepressant utilisation rates.

METHOD

This study was based at a metropolitan health service incorporating children's and adult hospitals. Total service utilisation of antidepressants was extracted from pharmacy software for the period January 2002 to December 2005. Monthly utilisation rates were computed for adults and children's services as defined daily doses (DDD) per occupied bed days. Changes in utilisation over time were examined for children and adults.

RESULTS

There was a significant relationship between time and antidepressant utilisation in children and adolescents, where antidepressant use decreased over time (R = 0.474; t = -3.66; p < 0.01), and in particular, use of SSRIs (R = 0.461; t = -3.52; p < 0.01). In contrast, use of SSRIs (R = 0.587; t = 4.91; p < 0.001) and all antidepressants (R = 0.327; t = 2.35; p < 0.05) increased over time in adults.

CONCLUSIONS

National and international warnings about safety of antidepressants in children and adolescents appear to have influenced local utilisation of these medications in young people but not in adults. Further research is required to determine optimal utilisation rates.

An absence of pediatric randomized controlled trials in general medical journals, 1985-2004

OBJECTIVE

There are numerous potential barriers to conducting randomized controlled trials (RCTs) in children. The purpose of this study was to compare the quantity, trends over time, characteristics, and quality of pediatric RCTs published in general medical journals (GMJs) with adult RCTs.

STUDY DESIGN AND SETTING

We conducted an electronic search of adult and pediatric RCTs from 1985-2004 and a manual search of published RCTs in the year 2000 in five high-impact GMJs (New England Journal of Medicine, Journal of the American Medical Association [JAMA], the Lancet, British Medical Journal [BMJ], Canadian Medical Association Journal [CMAJ]). Linear trends were identified and the 1-year sample was analyzed for publication characteristics (location of recruitment, sample size, number of centers, funding sources, and results) and quality scoring (Jadad score, intention-to-treat analysis, and citation frequency since publication).

RESULTS

Adult RCTs increased by 4.71 RCTs/year (95% confidence interval (CI) 3.62-5.80; P<0.001), which was significantly higher (P<0.0001) than pediatric RCTs, which increased by 0.4 RCTs/year (95% CI -0.02 to 0.9; P=0.06). Adult RCTs were more likely to be hospital-based (P=.001) and to involve more centers in multicenter studies (P=0.02). Quality scores were similar, although adult RCTs were cited more frequently (P=0.003).

CONCLUSION

There may be significant barriers to the publication of high-quality pediatric RCTs in GMJs.

Adolescent depression: challenges and opportunities: a review and current recommendations for clinical practice

Many aspects of the treatment for adolescent depression are still uncertain. However, our body of knowledge continues to accumulate, and our approaches continue to be refined. When we remember that 40 years ago the field was still arguing about the existence of depression in youth, it is clear that significant progress has been made. Recent controversies have provided another opportunity to step back and re-evaluate. Given the chronicity, morbidity, and mortality associated with adolescent depression, the risks of doing nothing are too great. Evidence-based research has provided us with some direction during this unsettling time. After careful reviews, the major professional organizations representing pediatric medicine and psychiatry all support the continued use of SSRI antidepressant medications but emphasize close monitoring. The debates also have heightened interest in effective psychotherapy approaches, particularly CBT and IPT. Given the risk for suicidality in depressed adolescents, assessment and management of safety concerns remain critical, regardless of medication usage. Above all, it is most important that we remain hopeful about our ability to guide adolescents and families through the struggles with depression toward recovery.

The use of antidepressants in school-age children

Approximately 5% of the pediatric population suffers from depression. Children suffering from depression should be treated first with some type of psychotherapy, cognitive therapy, and/or education. Pharmacotherapy (medications) should be used only as a last resort for those children suffering from severe, chronic, or recurring depression. The only antidepressant approved by the U.S. Food and Drug Administration for the treatment of depression in children is fluoxetine (Prozac), a selective serotonin reuptake inhibitor. In the school setting, children should be monitored closely upon the initiation of antidepressant therapy and changes in dosing or medication. They also should be monitored for side effects of the medication, response to therapy, and new signs of depression or worsening symptoms. After starting an antidepressant, children must be monitored closely for any changes in behavior, especially increased preoccupation with suicide. Any changes should be reported to the physician immediately for follow-up.