Comparison of medication, psychotherapy and ECT for the treatment of depression  in children and adolescents in the U.S.

Abstract

Childhood and adolescent depression is an ever-increasing health concern in the U.S. Adolescence, in particular, is a vulnerable time for this condition due to the many biological, cognitive and social-environmental changes that occur during this phase of life. Furthermore, depression in adolescence is a strong predictor of recurrent depression in adulthood and long-term functional impairment.

Three treatment approaches – psychotherapy, pharmacotherapy and electrical convulsive therapy (ECT) – were investigated to determine each treatment’s success and reliability when used to treat child and adolescent depression. It was concluded that one approach, ECT, while highly effective was underutilized and that a combined treatment plan might be most appropriate for this disorder.

Keywords and Definitions:

Allopathic medicine or mainstream medical uses pharmacologically active agents or physical interventions to treat or suppress symptoms or pathophysiologic processes of diseases or conditions.

http://englishdictionary.education/en/allopath

Cognitive behavioral therapy (CBT), developed by the psychiatrist, Aaron Beck, in the 1960s, is a short-term, goal-oriented psychotherapy method. It can be considered a combination of traditional psychotherapy and behavioral therapy.  It is based on the theory that much of how a person feels is determined by his personal way of thinking.

Dialectical behavior therapy (DBT) is a specific type of cognitive-behavioral psychotherapy developed by psychologist Marsha Linehan in the 1980s to help treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD) more effectively. It has been used for the treatment of other kinds of mental health disorders.

Electroconvulsive therapy (ECT) is a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental illnesses. It often works when other treatments are unsuccessful.

http://www.suttermedicalcenter.org/psychiatry/services/interventional/ect.php

Fluoxetine: (trade name: Prozac – Eli Lilly and Company) is an antidepressant of the selective serotonin reuptake inhibitor (SSRI) class. It is used for the treatment of major depressive disorder and several other psychological conditions.

https://en.wikipedia.org/wiki/Fluoxetine

Interpersonal therapy (IPT) is a brief, attachment-focused form of psychotherapy that centers on resolving interpersonal problems and symptomatic recovery. It is an empirically supported treatment (EST) that focuses on a patient’s relationships with his peers and family members and the way he sees himself. Interpersonal psychotherapy is a highly structured and time-limited approach that is intended to be completed in a 12-16 week period.

https://en.wikipedia.org/wiki/Interpersonal_psychotherapy

Monoamine-oxidase inhibitor (MAOI), first introduced in the 1950s, is a class of drugs designed for depression that inhibit the activity of the monoamine oxidase enzyme family. MAOI antidepressants prevent the breakdown of neurotransmitters, noradrenaline (norepinephrine) and serotonin, as it is theorized that an altered balance of serotonin and other neurotransmitters such as noradrenaline has a role in causing depression. This class of drugs can take up to three weeks to build up their effective chemical levels.

Selective serotonin reuptake inhibitor (SSRI) class of antidepressant drugs. See Fluoxetine – Prozac.

Tricyclic antidepressants (TCAs) are chemical compounds used primarily as antidepressants, discovered in the early 1950s and used primarily as antidepressant medication. They were named based on their chemical structure, which contains three rings of atoms.

Introduction:

There is a prevalence of major depressive disorder (MDD) being diagnosed in children and adolescents in the U.S. Despite the challenges in recognizing and properly diagnosing this condition, Clark reported that at least 2.8% of children under the age of 13 years and 5.6% of adolescents (ages 13 to 18) in the U.S. have experienced major depressive disorder. Numerous risk factors for childhood and adolescent depression have been recognized. Biological factors include low birth weight, gender, existing medical conditions and a family history of depression. Children between the ages of 3 to 5 diagnosed with certain health conditions, including diabetes mellitus or asthma were likely to have a major depressive episode. There can be environmental factors such as an instable home environment or deficient parenting skills that fail to provide adequate nurturing for the child or adolescent. Children of the age of 5 years who were considered “hostile” by their teachers were found to be at greater risk of depression Psychological, emotional and learning components can also contribute to depression in this young population.  As these factors are often intertwined, it becomes a greater challenge for health care providers to separate and identify these underlying components. (Clark et al, 2012)

In particular, adolescence is a vulnerable time due to biological, cognitive and social-environmental changes that become major risk factors. Clark et al report that while younger children with depression were more likely to have somatic symptoms, restlessness, separation anxiety, phobias, and hallucinations, adolescents were more likely to be unable to experience pleasure (anhedonia) as well as suffered from boredom, hopelessness, hypersomnia, weight change, alcohol or drug use, and suicide attempts. Zack found that more than half of all adolescents have reported experiencing depressed mood with 8% to 10% of this group showing clinically diagnosable symptoms. (Zach et al, 2012)

The Centers for Disease Control and Prevention indicated approximately four children out of every 500,000 below the age of 12 commit suicide each year. Even more alarming is the fact that this number has doubled since 1979. Suicide is the 14th leading cause of death for children. The suicide rate rises among adolescents aged 10 to 14 (1.3 per 100,000) and spikes among teenagers between the ages of 15 to 19 years (7.67 per 100,000). (Beam, 2010)

Depression is expensive in terms of personal lives, emotional and social well-being and academic learning as well as an economic burden to the individual and society. Zack stated that “depression in adolescence is a strong predictor of recurrent depression in adulthood and long-term functional impairment, and it confers a 10-fold increase in risk for suicidal behavior.” (Zach et al, 2012)

A study by Greenberg and colleagues (2015) examined costs associated with MDD, using data spanning from 2005, when the country’s finances and job markets were robust, to 2010, following the U.S. economic downturn. A total economic burden of MDD was estimated to be $210.5 billion per year. This demonstrated a 21.5% increase from $173.2 billion per year in 2005. Nearly half (48%-50%) of these costs are attributed to the workplace, including absenteeism and reduced productivity while at work. Approximately 45%-47% of the costs were direct medical costs (e.g., outpatient and inpatient medical services, pharmacy costs), which are shared by employers, employees, and society and 5% of the total cost was related to suicide. (Greenberg et al, 2015) (Kuhl, 2015)

Clark also found that approximately 60% of adolescents with depression have recurrences of depression throughout their adulthood, yet while the prevalence of adolescent depression was high, it was significantly under-diagnosed and therefore often untreated. Adolescent-onset depression was associated with many future adulthood problems including abuse and neglect, substance abuse, poor work performance and disruptions in social, employment and family settings. (Clark, 2012)

DoSomething.org, a global movement of 5.5 million young people focused on making positive change in the lives of young people provides these general facts about suicide:

• Nearly 30,000 Americans commit suicide every year.
• In the U.S., suicide rates are highest during the spring.
• Approximately 1 in 65,000 children (ages 10 – 14) commit suicide each year
• Suicide is the 3rd leading cause of death for 15 to 24-year-olds and 2nd for 24 to 35-year-olds.
• On average, 1 person commits suicide every 16.2 minutes.
• Each suicide intimately affects at least 6 other people.

It is therefore critical that health care providers accurately diagnose depression in children and adolescents and select the best medical care to provide rapid and effective relief. This treatment plan must consider various factors including the severity of depression, suicidality, developmental stage of the patient, and all environmental and social factors.

Use of Psychotherapy

Psychotherapy seems like a natural treatment for major depressive disorder, which is a “psychological” disorder. Both the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry recommend psychotherapy as a component in the treatment plan for children and adolescents suffering with depression.

A number of researchers supported this position. Zach reported that psychotherapy for depression was as effective as medication in many cases of depression and recommended its use as a primary treatment for mild to moderately depressed youths. Ryan’s research concluded that two types of psychotherapy, cognitive-behavioral therapy and interpersonal therapy, showed some effectiveness in the treatment of depression in children and adolescents. (Zach et al, 2012) (Ryan, 2005)

Clark point out however that the recommendation that psychotherapy be considered an acceptable treatment option should be applied for patients with milder depression and indicated that a combination of medication and psychotherapy was required in cases of moderate to severe depression. This position was supported by Giardino’s findings that cognitive-behavioral therapy (CBT) was effective in treating mild to moderate cases of depression in children and adolescents but that moderate to severe cases required a combined approach of psychotherapy and medication. (Clark et al, 2012) (Giardino et al, 2016)

In Zach’s research, he compared three types of psychotherapy for the treatment of depression in children and adolescents:

(1) Cognitive-behavioral therapy (CBT)

(2) Interpersonal therapy (IPT)

(3) Dialectical behavior therapy (DBT)

His work correlated with the Practice Parameters of the American Academy of Child and Adolescent Psychiatry (AACAP) that CBT alone was an effective treatment for mildly depressed youths, whereas moderately to severely depressed youths often required CBT (or other psychotherapies) along with antidepressants. Zach reported that the efficacy of IPT had not yet been established and had not been compared with the use of pharmacotherapy in an adolescent population. The NIMH did however conduct a study in which IPT was found to be as effective as imipramine in the treatment of MDD in adults.” (Zach et al, 2012)

Zach did find that “ adolescents who received DBT displayed greater reduction of symptoms, such as mood and self-injurious behavior along with improved relationships and overall functioning. He noted that DBT-A approach had not undergone randomized controlled trial data, and for this reason, Zack indicated that it should not be considered a well-established treatment for adolescents until further research had been performed. (Zach et al, 2012)

“The effects of CBT on depressive symptoms are moderate but it has not been proven more effective than placebo for treating acute depression in adolescents” was the conclusion of Clark. (2015) “Cognitive behavioral therapy (CBT), using behavioral activation techniques and coping skills to address negative thinking patterns and regulate emotions, has been proven effective with both children and adolescents. Interpersonal therapy, which focused on adapting to changes, personal role transitioning and interpersonal relationships, had also been effective with adolescents.” Clark concluded “a combination of CBT and medication has been shown to be more effective than medication alone in attaining remission of depression. Interpersonal therapy has not been compared with medication, combination treatment, or placebo, but it has been proven more effective than wait-list control groups with no therapy, and as effective or more effective than CBT.” (Clark et al, 2012)

Psychotherapy alone can be very slow and require mature insight that young children do not possess. Then there is the problem of impulsive adolescents who require immediate intervention to avoid such serious resultants of depression, such as suicide. It appears that for the severely depressed child or adolescent, the sole use of psychotherapy may not be adequate treatment.

Use of Medication

The health care industry is highly focused on pharmacological solutions for most disorders, including psychological disorders. The rate of antidepressant use in the U.S. continues to grow at alarming rates. Good news for the pharmaceutical industry but a serious concern for society.

Between 1999 and 2012, the number of Americans using antidepressants increased from 6.8% to 13%, according epidemiologist Elizabeth Kantor of Harvard University. The use of antidepressants has steadily grown at every two-year measuring period. (Kantor et al, 2015) The National Center for Health Statistics (NCHS) indicated that the rate of antidepressant use by adolescents and adults (people ages 12 and older) in the U.S. increased by almost 400% between1988–1994 and 2005–2008. (Wehrwein, 2011) Despite an increased use of antidepressants, a meta-analysis of antidepressant trials compared to therapy (published in JAMA Psychiatry in September, 2011) found no significant differences between antidepressants and CBT in response to treatment or remission in patients with severe depression. (Kantor et al, 2015)

Certain drugs marketed for the treatment of depression had been quite ineffective in the treatment of depression in children and adolescents and there was often increased issue of suicidal behavior. (Ryan, 2005)

Tricyclic and tetracyclic antidepressants, depending on the number of rings in their chemical structure — three (tri) or four (tetra) – were thought to lessen depression by impacting chemical messengers (neurotransmitters) used to communicate between neurons in the brain. Changes in brain chemistry and nerve cell communication in mood regulation regions of the brain was thought to help relieve depression. This class of drugs blocked the absorption (reuptake) of the neurotransmitters serotonin and norepinephrine, thereby increasing their levels in the brain. These drugs can however affect other neurotransmitters, resulting in various side effects. (Mayo Clinic Staff – Mayo Clinic, Diseases and Conditions – Depression)

The meta-analysis of 12 randomized double-blind placebo-controlled trials by Hazell et al found an overall small and clinically non-significant treatment effect of tricyclic drugs (TCA) in treating depression in children and adolescents. They reported that tricyclic antidepressants appeared to be no more effective than a placebo and concluded that tricyclic drugs should not be used as a primary treatment for depression for this population. (Hazell et al, 1995)

Findling also eliminated tricyclic drugs as a treatment for child and adolescent depression citing controlled clinical trials that had not demonstrated their efficacy in that population. They further point out the safety concerns of TCAs and the monoamine oxidase inhibitors and recommended newer drugs from the SSRI class. When compared with the TCAs, the SSRAs (fluoxetine/Prozac) were well tolerated by depressed youths based on open-label and double-blind studies and superior to placebo. The SSRI’s were also more reliable in preventing overdose. (Findling et al, 1999)

The National Institute of Care and Clinical Excellence (NICE) recommended SSRI antidepressant treatment in combination with psychosocial interventions as a first line treatment for severe and moderate depression, as well as recurrent depression and as a second-line treatment for short-term mild depression. The American Psychiatric Association also included SSRI antidepressant therapy among its primary treatment options for depression, particularly when there was a patient history of prior positive response to medications.

Emslie (2002) conducted a 9-week acute treatment double-blind clinical trial to test designed to test the findings of previous studies of fluoxetine in the treatment of children and adolescents with MDD. SSRls were recommended because of their low lethality on overdose and ease of administration (AACAP, 1998). Using the Children’s Depression Rating Scale-Revised (CDRS·R) score showed patient s using fluoxetine improved more when compared to patients receiving a placebo after 1 week (p < .05) and throughout the study. Their conclusion was that a 20 mg daily dose of fluoxetine was well tolerated and effective for acute treatment of child and adolescent outpatients with depression. Fluoxetine was noted as the only antidepressant that had demonstrated efficacy In two placebo-controlled, randomized clinical trials of pediatric depression. (Emslie et al, 2002)

In a 36 week, double-blind study, fluoxetine alone or in combination with CBT resulted in an accelerated improvement of depression when compared to CBT or a placebo alone. When CBT was added to the fluoxetine therapy, there was a decrease in persistent suicidal ideation and treatment-emergent suicidal events

Rates of response were: