Depressed teens get relief by switching drugs

Nearly half of teenagers struggling with depression get little help from antidepressant drugs. But a new study shows that simply switching to another antidepressant can dramatically improve treatment success.

Adding psychotherapy further increases the chances of pulling out of depression's downward spiral.

"If you don't respond to an initial treatment, don't give up hope," said psychologist Greg Clarke, a senior investigator at Kaiser Permanente's Center for Health Research in Portland, Ore., and a study co-author.

The findings in teenagers match earlier results in adults. But the federally funded study, appearing last month in the Journal of the American Medical Association, is the first clinical trial to focus on teenagers who have failed to gain help from a first course of treatment for depression. It also is the first large-scale antidepressant study to include teenagers whose depression has driven them to suicidal thoughts or attempts, making its findings particularly applicable to difficult real-life situations.

Researchers in seven cities studied more than 300 teenagers with depression who had failed to improve after two months of treatment with one type of antidepressant drug, selective serotonin reuptake inhibitors, or SSRIs.

They split the teens into four groups: One switched to a different brand of SSRI; another tried Effexor, one of a newer class of antidepressants called serotonin and norepinephrine reuptake inhibitors, or SNRIs; the final two groups tried one or the other class of drugs in combination with cognitive behavioral therapy, psychotherapy emphasizing problem-solving and behavior change.

Those receiving cognitive behavioral therapy plus a drug fared best; nearly 55 percent gained significant relief from depression. The severity of their symptoms declined by at least 50 percent, and a therapist judged their overall condition as improved or very much improved.

An earlier federal study showed that teenagers newly diagnosed with depression benefit most from medication and psychotherapy, and many experts now think that is the ideal first line of treatment.

In practice, therapy goes underused because of a shortage of therapists and lack of interest among patients, said Dr. David Brent of the University of Pittsburgh, the study's lead author.

Though drugs alone aren't as effective, about 41 percent of teenagers in the study who switched to another medication, regardless of the drug brand or class, gained significant relief.

None of the antidepressant drugs outperformed the others. But teenagers taking Effexor, the SNRI, incurred more side effects, including skin infections and cardiovascular symptoms, than those taking any of the older SSRIs: Prozac, Paxil and Celexa.

The study provided no answer to one looming question: how antidepressant drugs might increase suicide risk. Clarke said previous clinical trials comparing antidepressants with a placebo suggest the drugs can increase suicidal thoughts in a fraction of teenagers — about two or three per 100 taking the medications.

The new study didn't include a placebo group. But suicidal thoughts declined at about the same rate in each treatment group.

"Combination treatment is the best choice," he said. "But if that is not available, I would have no hesitation recommending medication. The most important thing is to not let the depression go on and on and on."