Treating depressed teenagers with a combination of cognitive behavioral therapy and fluoxetine, an antidepressant medication, seems to offer better results than either medication alone or cognitive behavioral therapy alone, according to an article in Archives of General Psychiatry (JAMA/Archives).

The authors explain that 5% of teenagers are affected by major depressive disorder – this causes great difficulties for the patient and his/her family, explain the authors.

The National Institute of Mental Health (NIMH) in 1999 funded the Treatment for Adolescents with Depression Study (TADS). TADS was a randomized controlled trial which evaluated short-term and long-term effectiveness of three types of treatment: 1. Just fluoxetine. 2. Just cognitive behavioral therapy*. 3. A combination of fuoxetine and cognitive behavioral therapy.

*(Cognitive Behavioral Therapy focuses on how you currently think an act rather than past events)

439 teenagers, average age 14.6 years, with depression were randomly assigned to one of the three treatments, or placebo pills, for a period of 12 weeks. At 12 weeks those who had been on the placebo pill were offered active treatment – the other 327 patients continued their therapy through 36 weeks.

Fluoxetine was prescribed at 10 milligrams per day initially, this dosage was decreased or increased during the treatment period depending on whether they responded to the medication or experienced adverse events. The children who received cognitive behavioral therapy had 15 one-hour sessions during the first 12 weeks, then less often, depending on how they had responded to treatment.

At the end of the twelve-week period, 73% of patients receiving combination therapy, 62% of those receiving fluoxetine only and 48% of those undergoing cognitive behavior therapy responded to treatment, as measured by two clinical scales.

At the end of the 36-week period, 74.3% (243) of the 327 patients remained in the study. The combination therapy response rate was 86%, 81% for fluoxetine and 81% for cognitive behavioral therapy.

During the whole treatment period the children were monitored for suicidal thoughts and behaviors.

At the beginning of the study, 39.6% (42 of 106) of those in the combination therapy group, 26.2% (28 of 107) of those in the fluoxetine group and 25.2% (27 of 107) of those in the cognitive behavior therapy group warranted prompt evaluation for suicidal tendencies.

At 12 weeks of treatment the fuoxetine group reported more clinically significant suicidal thoughts and behaviors than the other two groups.

At 36 weeks of treatment, 2.5% (2 of 79) of the combination therapy patients, 13.7% (10 of 73) of those taking fluoxetine alone and 3.9% (3 of 76) of those receiving cognitive behavior therapy reported experiencing significant suicidal thoughts and behaviors.

The authors wrote “Patients treated with fluoxetine alone were twice as likely as patients treated with combination therapy or cognitive behavior therapy to experience a suicidal event, indicating that cognitive behavior therapy may protect against treatment-emergent suicidal events in patients taking fluoxetine. After taking benefit and risk into account, we conclude that the combination of fluoxetine and cognitive behavior therapy appears superior to either monotherapy (single treatment) as a long-term treatment strategy for major depressive disorder in adolescents.”

Arch Gen Psychiatry. 2007;64(10):1132-1144

Written by: Christian Nordqvist