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The Wall Street Journal
By SHIRLEY S. WANG
October 2, 2007
A combination of medication and therapy helps depressed adolescents heal faster than medication or therapy alone, and with fewer incidents of the suicidal tendencies associated with unalloyed antidepressant use, according to findings in the largest and longest government-funded study of depressed teenagers.
Researchers, doctors, and therapists have struggled with two major concerns in treating depression: The possibility antidepressants may promote suicidal thoughts, and the difficulty of helping adolescents recover from the illness over the long run. This study, published yesterday in the Archives of General Psychiatry, provides more evidence that a combination of the antidepressant Prozac and therapy can help overcome both problems. [See Press Release]
The study’s authors say the findings offer hope that teenagers can attain long-term recovery from the illness, which is marked by chronic relapses among patients of all ages. They hope that by treating adolescents for longer than three to four months — the typical duration of such studies — teens will reach their “maximal medical benefit” from treatment and be less likely to become depressed again in the future, said John March, chief of Child and Adolescent Psychiatry at the Duke University School of Medicine and one of the study’s authors.
While previous studies showed these treatments could work in adolescents, they didn’t focus on long-term maintenance as this study did, according to Thomas Ollendick, a psychology professor at Virginia Tech who researches cognitive-behavior therapy, or CBT, but wasn’t involved in this study.
The 327 adolescents in the $17 million trial, the Treatment for Adolescents with Depression Study, spent nine months undergoing one of three treatments — medication alone, CBT alone, or both at once — and showed similar improvement across all three groups. Those receiving combined treatment had the fastest turnarounds.
“The idea is that if you want to get the most kids better the quickest, you’re going to use the combination treatment,” Dr. March said. “CBT catches up; it just takes a long time.”
Depressive symptoms decreased in 81% of adolescents receiving only psychotherapy or drugs, and in 86% of those getting both treatments.
These data fit in nicely with findings in the depression field as a whole, which generally show that medication works faster than psychotherapy alone, according to Dr. Ollendick. “If you can produce quick symptom change with pharmacology, and then build skills and modify faulty cognitions using CBT, you have the best of both worlds,” he said.
Therapy appears to be important in reducing suicidal thoughts. Such thoughts decreased over time on average for all study participants. However, while nearly 15% of those only taking Prozac — Eli Lilly & Co.’s brand-name fluoxetine drug — expressed serious suicidal thoughts or attempts, that number dropped to 8.4% when combined with therapy, much closer to the 6.3% of teens in therapy who weren’t medicated.
“CBT seems to protect you, if you’ve gotten medication, from one of these suicidal events,” said Dr. March.
The rate of suicidal thoughts — which this study doesn’t suggest are caused by the antidepressant — is still “too high,” said Dr. Ollendick. “That to me argues against medication alone as an acceptable treatment.”
When short-term results of the study were published three years ago, critics raised concerns that the issue of suicidal thoughts among those on medication alone was minimized. They also said the conclusion that medication is a necessary component of the preferred treatment was too strongly stated.
A major concern about the latest findings is whether the patients improved because of the treatment or just felt better naturally over time. The study didn’t have an untreated control group to compare for the final six months.
The study was funded by the National Institute of Mental Health. Eli Lilly provided the medication and placebo but wasn’t involved in any other aspect of the study, according to Dr. March, who has served as a consultant for several pharmaceutical companies but does no promotional work.