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Rapid Responses: Rapid Responses published:
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Not a trial of antidepressants
- Jon N Jureidini (18 June 2007)
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Response to Jureidni
- Ian M Goodyer (26 June 2007)
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Both groups had "combined treatment"
- Diane Civic (24 July 2007)
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Re: Both groups had "combined treatment"
- Ian M Goodyer (15 August 2007)
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Jon N Jureidini, Head, Dept Psychological Medicine Women's & Children's Hospital, Adelaide
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This paper tells us something about the role of Cognitive Behaviour Therapy (CBT) in adolescent depression, but nothing about the use of drugs. The response rate is not strikingly different from what would be expected from placebo, and as with other studies of combinations of antidepressant and CBT, <1> we can draw no conclusions about the efficacy of antidepressants in the absence of a placebo arm. The authors justify that absence on the basis that a placebo arm would 'be unethical in such ill patients'. That justification is questionable, given that at least 19 out of 20 studies of newer antidepressants in children and adolescents fail to show meaningful advantage to drug over placebo on their primary outcomes.<2> Whilst Goodyer et al make few direct claims about the effectiveness of antidepressants, the implication that benefit is attributable to drug will likely be used by others to support prescribing. 1. Jureidini J, Tonkin A, Mansfield P. (2004) TADS study raises concerns BMJ 329:1343 2. Mansfield PR. Trials of newer antidepressants for depressed children and/or adolescents. March, 2007. http://www.healthyskepticism.org/documents/documents/Trialstable.pdf (accessed June 2007) Competing interests: None declared |
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Ian M Goodyer, Professor of Child and Adolescent Psychiatry Developmental Psychiatry, Douglas house, 18b Trumpingotn Road, Cambridge, CB2 8AH
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Jureidini is correct in reminding readers that the ADAPT trial is not a test of the efficacy of Fluoxetine over psychological treatments. I do not agree with his assertion that it is acceptable to use a placebo arm in a pragmatic effectiveness trial of treatment for adolescent depression. There is evidence that active treatment involving interventions of a psychological or a pharmacological nature is effective compared with a neutral passive placebo. Active psychological treatment is more successful than placebo in symptom reduction in the community 1 and fluoxetine is effective in accelerating the response rate in more moderate to severe depressions 2. Under current UK ethical guidelines and given the available evidence it is possible that the use of a neutral placebo would be considered as exposing depressed adolescents to greater risk than benefit. I also disagree with Jureidin’s negative perspective of the use of fluoxetine and would guard against the implications of not considering medication in depressed adolescents who have proven resistant to psychosocial treatment approaches or failed to show an improvement after 10 weeks following referral to CAMHS. A significant proportion of depressed young people are hard to treat and will become chronic mentally ill young adults 3. We require a substantial improvement in the evidence base for treatment in both community and clinically referred samples before definitive treatment protocols can be fully developed. 1. Merry S, McDowell H, Wild CJ, Bir J, Cunliffe R. A randomized placebo-controlled trial of a school-based depression prevention program. J Am Acad Child Adolesc Psychiatry 2004;43(5):538-47. 2. Kratochvil C, Emslie G, Silva S, McNulty S, Walkup J, Curry J, et al. Acute time to response in the Treatment for Adolescents with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry 2006;45(12):1412-8. 3. Dunn V, Goodyer IM. Longitudinal investigation into childhood- and adolescence-onset depression: psychiatric outcome in early adulthood. Br J Psychiatry 2006;188:216-22. Competing interests: None declared |
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Diane Civic, Clinical Epidemiologist Group Health, Seattle, WA 98112
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In the Goodyer et al. study(1), patients in the SSRI alone group received a “routine clinical care” intervention consisting of nine or more treatment sessions that included problem-solving, family support, psychoeducation and addressing co-morbidities. While this may be routine care in the UK, this is not the case in the US where patients may receive a prescription for an SSRI from a family practice provider with no additional care other than (hopefully) monitoring of side effects and suicide ideation. In the Treatment for Adolescents wtih Depression Study (TADS), patients in the fluoxetine only group were offered six 20-30 minute medication monitoring visits that had no psychotherapy component, only “general encouragement about the effectiveness of pharmacotherapy for MDD (major depressive disorder)(2). To me, the findings of the Goodyer et al. study complement the findings of TADS, rather than contradict them. One cannot conclude from the Goodyer et al. study that adding a behavioral health intervention to SSRI treatment is ineffective since the control group received a type of combined treatment. I might conclude, instead, that adding this particular cognitive-behavioral therapy intervention to a routine behavioral health intervention does not appear to be beneficial. (1) Goodyer I et al. Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care wtih and without cognitive behavior therapy in adolescents with major depression: randomized controlled trial. BMJ 2007: 335: 142. (2) Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression. JAMA 2004; 292: 807-820. Competing interests: None declared |
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Ian M Goodyer, Professor of Child and Adolescent Psychiatry University of Cambridge, Douglas House, 18b Trumpingotn Road, Cambridge , England, CB2 8AH
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Dr Civic is correct in noting that both arms of the ADAPT study received active clinical care which is indeed standard treatment in the Uk although likely to be delivered with variable quality from one adolescent mental health service to another. Furthermore in our design we excluded a number of cases (n=34, see figure 1 of the published paper, (1)) who responded solely to the brief behavioural intervention. There is suprisingly little known about the treatment effects of these types of straightfoward interventions for adolescents with depression. They may represent a relatively effective and more straightforward behavioural intervention that could be delivered by many mental health professionals in community and specialist mental health services. The focus on using more complex CBT approaches that require highly trained staff are potentially more expensive and , in the UK at least, relatively scarce, and not supported by the ADAPT findings. It is rather worrying to hear that depressed teens in the USA may be receiving sub-optimal or even negligible psychological interventions , a fact supported by some recently published findings on USA prescribing rates of antidepressants in young people (2). Future randomized controlled trials in community settings for mild to moderate depressions might usefully consider comparing a low intensity brief active clinical intervention such as delivered in ADAPT against a more high intensity specialist CBT approach to determine how effective the more simpler to deliver intervention really is. (1) Goodyer I et al. Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care wtih and without cognitive behavior therapy in adolescents with major depression: randomized controlled trial. BMJ 2007: 335: 142. (2) Olfson M., Gameroff,MJ., Marcus SC., Waslick B (2003) Outpatient treatment of child and adolescent depression in the united states. Arch Gen Psych 60: 1236-1242 Competing interests: None declared |
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