New-generation antidepressants, suicide and depressed adolescents: how should clinicians respond to changing evidence? Aust N Z J Psychiatry

Adolescent Service, Prince of Wales Hospital, Randwick, Australia. m.dud
Australian and New Zealand Journal of Psychiatry (Impact Factor: 3.41). 07/2008; 42(6):456-66. DOI: 10.1080/00048670802050538
Source: PubMed


The purpose of the present paper was to identify, from the voluminous literature on efficacy and safety in new-generation antidepressants (NGAs) with depressed children and adolescents, practical clinical strategies for acute phase treatment. To this end a pragmatic survey of studies and reviews was undertaken. Meta-analyses of randomized controlled trials of NGAs in depressed children and adolescents have noted a comparative lack of efficacy, and a weak but statistically significant increased risk of self-harm and suicidal thoughts. But NGA prescription rates and youth suicide rates are generally inversely related, and ensuing 'black box' warnings about NGAs, by deterring NGA prescribing, have possibly contributed to rising youth suicide rates. In moderate-severe depression, benefits for fluoxetine and possibly other NGAs demonstrably outweigh risks. NGAs are not present in adolescents who die by suicide. Concern about NGA risks must be balanced against risks of non-treatment. While mild depression entails regular review, psychoeducation, self-care strategies and psychological interventions, NGAs should be administered concurrently with psychological treatments if depression is moderate- to severe, or if mild depression persists. Patients should be warned about off-label status of NGAs in depression, serious side-effects such as 'activation', suicidality, emotional blunting and manic switches, the need for adherence and avoiding abrupt discontinuation. They should be monitored early and regularly. Better evidence is required regarding psychological treatments, clinical course, and clinical practice trends. In moderate-severe depression the risk of suicide if NGAs are not used may outweigh any risk of self-harm associated with them.

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    • "The evidence for treatments of adolescent depression is less well established than for adult populations [8]. A number of comprehensive reviews and meta-analyses show that there is limited evidence and the existing findings have not established the efficacy for either pharmacological or current psychological therapies for youth depression, anxiety and comorbid alcohol or drug abuse [10-12]. A number of psychological therapies have been supported for use with depression, anxiety and alcohol or drug abuse in adult studies, and have some limited support for use with adolescents. "
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    ABSTRACT: There is increasing community and government recognition of the magnitude and impact of adolescent depression. Family based interventions have significant potential to address known risk factors for adolescent depression and could be an effective way of engaging adolescents in treatment. The evidence for family based treatments of adolescent depression is not well developed. The objective of this clinical trial is to determine whether a family based intervention can reduce rates of unipolar depressive disorders in adolescents, improve family functioning and engage adolescents who are reluctant to access mental health services. The Family Options study will determine whether a manualized family based intervention designed to target both individual and family based factors in adolescent depression (BEST MOOD) will be more effective in reducing unipolar depressive disorders than an active (standard practice) control condition consisting of a parenting group using supportive techniques (PAST). The study is a multicenter effectiveness randomized controlled trial. Both interventions are delivered in group format over eight weekly sessions, of two hours per session. We will recruit 160 adolescents (12 to 18 years old) and their families, randomized equally to each treatment condition. Participants will be assessed at baseline, eight weeks and 20 weeks. Assessment of eligibility and primary outcome will be conducted using the KID-SCID structured clinical interview via adolescent and parent self-report. Assessments of family mental health, functioning and therapeutic processes will also be conducted. Data will be analyzed using Multilevel Mixed Modeling accounting for time x treatment effects and random effects for group and family characteristics. This trial is currently recruiting. Challenges in design and implementation to-date are discussed. These include diagnosis and differential diagnosis of mental disorders in the context of adolescent development, non-compliance of adolescents with requirements of assessment, questionnaire completion and treatment attendance, breaking randomization, and measuring the complexity of change in the context of a family-based intervention.Trial registration: Australia and New Zealand Clinical Trials Registry Title: engaging youth with high prevalence mental health problems using family based interventions; number 12612000398808. Prospectively registered on 10 April 2012.
    Trials 11/2013; 14(1):384. DOI:10.1186/1745-6215-14-384 · 1.73 Impact Factor
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    • "US research based on data submitted to the Food and Drug Administration (FDA) has shown those up to the age of 25 treated with antidepressant medication are more likely to experience an increase in suicidal ideation and suicide attempts [8-10] resulting in controversy about what constitutes optimal treatment for youth depression [11-14]. We sought to identify the impact of this on clinicians’ implementation of guideline recommendations in a public youth mental health service. "
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    ABSTRACT: Literature has shown that dissemination of guidelines alone is insufficient to ensure that guideline recommendations are incorporated into every day clinical practice. We aimed to investigate the gaps between guideline recommendations and clinical practice in the management of young people with depression by undertaking an audit of medical files in a catchment area public mental health service for 15 to 25 year olds in Melbourne, Australia. The results showed that the assessment and recording of depression severity to ensure appropriate treatment planning was not systematic nor consistent; that the majority of young people (74.5%) were prescribed an antidepressant before an adequate trial of psychotherapy was undertaken and that less than 50% were monitored for depression symptom improvement and antidepressant treatment emergent suicide related behaviours (35% and 30% respectively). Encouragingly 92% of first line prescriptions for those aged 18 years or under who were previously antidepressant-naïve was for fluoxetine as recommended. This research has highlighted the need for targeted strategies to ensure effective implementation. These strategies might include practice system tools that allow for systematic monitoring of depression symptoms and adverse side effects, particularly suicide related behaviours. Additionally, youth specific psychotherapy that incorporates the most effective components for this age group, delivered in a youth friendly way would likely aid effective implementation of guideline recommendations for engagement in an adequate trial of psychotherapy before medication is initiated.
    BMC Health Services Research 06/2012; 12(1):178. DOI:10.1186/1472-6963-12-178 · 1.71 Impact Factor
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    ABSTRACT: Analyzed English and Welsh patient statistics and symptomatological surveys. It is argued that these data do not provide adequate grounds for conclusions. The overrepresentation of females among the mentally ill is relatively recent and is a function of which disturbances are considered mental illness and of marital status. It is pointed out that among single persons (who have the highest rate of hospitalization) males predominate, whereas among married persons (the majority of patients) females have higher rates. In Britain, one reason for the female preponderance is the number of patients over 65 yrs of age, most of whom are female. It is contended that the true prevalence of sex differences in mental illness cannot be determined because sex bias is built into the diagnostic criteria; epidemiological studies should be evaluated with caution because psychiatric classification is a function of historical and social forces. (32 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
    International Journal of Mental Health 03/1982; 11(1-2):46-66. DOI:10.1080/00207411.1982.11448905
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