Maintaining Treatment of Depression in Adolescents Increases Remissions

Anew study shows that the rate of remission in adolescents treated for depression for 36 weeks was more than double that of adolescents treated for 12 weeks, whether treatment was with an antidepressant, cognitive-behavioral therapy, or a com­bination of both.¹

Although the remission rate from the 12-week acute treatment phase was previously reported to be a relatively low 23%, the current study of treatment maintained for an additional 36 weeks found a remission rate across groups of about 60%.² The investigators note that this is comparable to the overall cumulative rate of 67% reported for adults in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial.³ Betsy Kennard, PsyD, and colleagues in the Treatment for Adolescents With Depression Study (TADS) indicated that “these findings highlight the importance of continuation and maintenance phase treatments, as the rates of remission improve with time and continued treatment.”

The investigators point out that the measure for remission-complete or nearly symptom-free status-is substantially more stringent than for response to treatment; and that there have been few studies of remission in adolescents with depression and even fewer involving extended treatment. TADS is notable for also comparing the effectiveness of 3 treatment modalities beyond the acute (12-week) and continued (12- to 18-week) phases, through 36 weeks of maintenance.

Remission rate differences between the groups were apparent only in early treatment. The combination of fluoxetine (Prozac) and cognitive-behavioral therapy was associated with the highest rate of remission as early as week 6, and remained superior to both monotherapies at weeks 12 and 18. By week 24, however, the rates of remission were similar-and that pattern corresponded to the earlier reported similarity of the groups in response to treatment.⁴

Although similar remission rates were ultimately achieved with each treatment modality, the investigators consider the early superiority of the combination treatment over mono­therapy with either the medication or cognitive-behavioral therapy to be significant. “Selecting a monotherapy could mean delay of remission for a substantial number of depressed adolescent patients by 2 to 3 months,” Kennard and colleagues said. The comparable benefit could be interpreted to indicate that time rather than treatment was the critical factor in the improvement; the investigators cite other long-term follow-up reports in which experimental and control groups had similar outcomes.5 Kennard and colleagues argue, however, that their reported remission rates generally reflect treatment effect, since the mean duration of depressive episodes before baseline was more than 1 year, and that more than half the cohort had been previously treated and remained symptomatic. “Thus, in our sample, spontaneous remission is unlikely because of the illness severity in these patients and past treatment of this sample,” they conclude.

Of the patients who achieved remission in the 12-week acute treatment phase, 65% to 72% maintained it through the 36 weeks of continued treatment, meeting the American College of Neuropsychopharmacology criteria for full recovery-sustained remission for at least 16 weeks.

Although the rate of remission increased with time, a substantial number of patients remained symptomatic, and approximately one-third of the patients who attained an early remission subsequently experienced a relapse within 36 weeks. The failure to attain or maintain remission with pharmacotherapy, cognitive-behavioral therapy, or a combination of both therapies points to the remaining challenge in treatment, the investigators observed.

“It highlights the need to continue to monitor patients even after they have reached remission status.”

References:

1. Kennard B, Silva S, Tonev S, et al. Remission and recovery in the Treatment for Adolescents With Depression Study (TADS): acute and long-term outcomes. J Am Child Adolesc Psychiatry. 2009;48:186-195.
2. Kennard B, Silva S, Vitello B, et al; TADS Team. Remission and residual symptoms after short-term treatment in the Treatment of Adolescents With Depression Study (TADS). J Am Acad Child Adolesc Psychiatry. 2006;45:1404-1411.
3. Rush AJ,Trivedi MH,Wisniewski SR, et al.Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163:1905-1917.
4. March JS, Silva S, Petrycki S, et al. The Treatment for Adolescents With Depression Study (TADS): longterm effectiveness and safety outcomes [published correction appears in Arch Gen Psychiatry. 2008; 65:101]. Arch Gen Psychiatry. 2007;64:1132-1143.
5.Weersing VR,Weisz JR. Community clinic treatment of depressed youth: benchmarking usual care against CBT clinical trials. J Consult Clin Psychol. 2002; 70:299-310.