Study offers hope for addicted, sad teens

Bill Scanlon, Rocky Mountain News

Published November 8, 2007 at midnight

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Depressed teens who also abuse drugs can be treated safely with antidepressants and therapy to help them better cope with their addictions, a team of Colorado researchers has found.

The landmark study of 126 Colorado teens is good news to clinicians, who'vebeen unable to help depressed, addicted teens because they haven't known whether antidepressants are safe for them.

Teens who feel sad or angry all the time, often become their own druggists, turning to marijuana, amphetamines or alcohol.

Although such teens number more than a million, they rarely get the help they need.

They're barred from clinical trials until they sober up, something difficult enough for any addict, much more so for a teen also struggling with mental problems.

Dr. Paula Riggs and her colleagues at the University of Colorado Denver School of Medicine tracked 126 Colorado teens who've exhibited bad behavior, major depression and a history of abusing at least one drug.

Riggs found that when you give these teens fluoxetines, such as Prozac, and combine it with therapy aimed at changing their addictive behavior and giving them coping skills, some three-fourths of them see big drops in their depression after four months. The study appears in Archives of Pediatrics & Adolescent Medicine.

What comes first, the depression or the addiction? It's about 50-50, Riggs said. Researchers know that mental illness is three or four times higher in teens with substance abuse issues.

Riggs' study showed antidepressants and therapy not only brightened the teens' mood, but helped them kick addictions.

Studies in 2003 and 2004 linked antidepressants with an increase in teen suicide. Subsequent studies have debunked some of that link, but not all of it. Teens using antidepressants are 52 percent more likely to commit suicide, according to a study by Columbia University. But since it's the depressed teen who gets the antidepressants, it is just as likely that the mental state, not the drugs, led to the suicide attempt, many scientists say.

The same authors found that between 1990 and 2000, the areas of the nation that had the biggest rise in antidepressants for teens also had the biggest drop in teen suicides.

Riggs' study found that depression largely disappeared in 76 percent of the teens who got both the medication and the behavior-cognitive therapy. Also, 67 percent of those who got just therapy, but not medication, saw their depression lift. In both groups, if the depression lifted, substance abuse dropped.

"These kids come to drug treatment with only one tool in their tool bags," Riggs said. "If their dog dies? 'I think I'll get high.' If their girlfriend breaks up with them? 'I think I'll get high.'

Therapists help them cope with craving, make decisions, solve problems.

"You are bummed out and depressed? What else can you do?"

The rewards can be as lofty as making their parents happy or as self-centered as being able to use the car after a drug-free month.

"Kids don't come to treatment and say, 'Doc, I hit rock bottom. I'm going to quit,'" Riggs said. "We have to meet them where they are," with medications and an empathetic but firm therapy coach.

scanlon@RockyMountainNews.com

or 303-442-8729

"An important clinical implication of these results may be that in the context of cognitive behavior therapy (substance abuse treatment), co-occurring depression may significantly improve or remit without antidepressant pharmacotherapy," said Riggs. "However, if depression does not appear to be improving early in the course of substance treatment, should be considered even if adolescents are not yet abstinent, with weekly monitoring of treatment adherence, substance use, adverse effects and target symptom response.

Considered, August 17, 2004 ? A study in this week's Journal of the American Medical Association shows that Prozac in combination with a form of psychotherapy called cognitive behavioral therapy is highly effective for treating depression in teens. But the study also shows a small increase in "harm-related behaviors," including suicide attempts, among teens on Prozac. NPR's David Baron reports.

the study, researchers at Columbia University reviewed the medical records of 4,419 Medicaid patients who had been hospitalized for severe depression. According to the analysis, use of antidepressants — including Wellbutrin, Effexor and SSRIs, such as Prozac, Paxil and Zoloft — was significantly linked to suicide and suicide attempts in young patients. In adults, however, no such link emerged.

Children and teens, aged 6 to 18, who took antidepressants were 52% more likely to attempt suicide than their peers who weren't taking medication. They were also 15 times more likely to succeed in their attempts. The numbers sound dramatic, but researchers caution that their findings be carefully considered. Of the study group, only eight children completed suicide — a small number on which to base a generalization. Further, it's still unclear whether the suicidal urge is related more to the medication or to the underlying depression. "It is possible that antidepressant drugs are selectively prescribed to more severely depressed children and adolescents," write the authors, "and that these more severely depressed youths are also at increased risk for suicidal behavior."

What It Means: Giving antidepressants to children is a tough call. It could be risky to put your child on an SSRI, but it could be devastating not to. A 2003 study by the same authors found that the U.S. regions where antidepressant prescriptions to young people increased the most between 1990 and 2000 were the same regions that saw the biggest dips in youth suicide.

If your child is currently on an antidepressant, don't alter or stop treatment without talking to your doctor. If your child is just

th a 16-week clinical trial ...

AURORA, Colo. (Nov. 5, 2007) – New research from the University of Colorado Denver School of Medicine has found that a common antidepressant is showing promising success when combined with cognitive behavior therapy to treat adolescents with depression and substance use disorders . The report was published in the November issue of Archives of Pediatrics & A dolescent Medicine, one of the JAMA/Archives journals. The landmark study titled "A Randomized Control Trial of Fluoxetine and Cognitive Behavioral Therapy in Adolescents with Major Depression, Behavior Problems and Substance Use Disorders" is the first randomized controlled trial of combined pharmacotherapy for depression and behavioral intervention for substance use disorders in adolescents.

Research has shown that depression among adolescents with substance use disorders is three to four times greater than in adolescents without substance abuse and is associated with more severe substance abuse, poorer treatment outcomes and higher relapse rates. However, little is known about the safety and efficacy of medications in adolescents with substance abuse since such youths have been systematically excluded from pharmacotherapy studies. As a result, clinicians have been reluctant to treat depression (and other common co-occurring disorders) in adolescents with substance use disorders.

To bridge this clinical and research gap, Paula Riggs, MD, and colleagues at the UC Denver School of Medicine conducted a 16-week randomized controlled trial of the antidepressant fluoxetine in 126 teens (average age 17) who met diagnostic criteria for major depressive disorder, lifetime conduct disorder and at least one substance abuse disorder other than tobacco.

"The primary aims of the study were to evaluate the safety and efficacy of fluoxetine for depression and the impact on substance use, conduct problems and other substance treatment outcomes," said Riggs.

The adolescents were randomly assigned to receive either 20 milligrams of fluoxetine daily or a placebo, along with cognitive behavioral therapy (CBT) focused on substance abuse rather than depression.

"The weekly, individual cognitive behavioral therapy helps adolescents improve their decision-making skills as well as their coping, communication, and drug-refusal skills, added Riggs. "It also helps adolescents learn ways to avoid high-risk situations and increase their motivation and involvement in pro-social activities that are incompatible with drug use."

The study found fluoxetine combined with CBT was well-tolerated and had greater efficacy than the placebo with CBT on the Childhood Depression Rating Scale-Revised but not on the Clinical Global Impression Improvement measure of treatment response. Drug use and conduct disorder symptoms decreased significantly in both the fluoxetine and placebo treatment groups but there was no difference between fluoxetine and placebo treatment on either variable. The rate of treatment retention/completion (84 percent) was higher and reduction in drug use similar to that reported for other evidence-based substance treatment modalities in adolescents with less psychopathology.

The higher than expected rate of treatment response (CGI-I) in the placebo + CBT (67 percent) as well as the fluoxetine + CBT (76 percent) treatment group may indicate that CBT contributed to depression treatment response, despite its focus on substance abuse. Adolescents whose depressions remitted (regardless of medication group assignment) significantly decreased their drug use whereas drug use did not decrease in those whose depressions did not remit.

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