Treatment for Adolescents With Depression Study (TADS)
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Transcript of Treatment for Adolescents With Depression Study (TADS)
Treatment for Adolescents With Depression Study
(TADS)
Fluoxetine, Cognitive Behavioral
Therapy, and Their Combination for
Adolescents With Depression
Treatment for Adolescents With Depression Study (TADS) Team
JAMA 2004: Vol 292, No. 7
TADS
A randomized controlled trial funded by the National Institute of Mental Health
Conducted at 13 academic and community centers in the United States
To evaluate the effectiveness of treatments for adolescents with MDD
Participants
429 patients Age 12 -17 years (mean age 15 years) Primary diagnosis of major depressive
disorder (DSM-IV)
Inclusion Criteria
Outpatient CDRS ≥ 45 IQ ≥ 80 Not taking antidepressants Depressive mood in at least 2 contexts for at
least 6 weeks prior to consent
Exclusion criteria
Bipolar disorder Severe conduct disorder Substance abuse PDD Thought disorder Concurrent psychotropic medications Failed 2 SSRIs or CBT
Exclusion criteria
Dangerousness to self or others Had been hospitalized for dangerousness
within 3 months Suicidal attempt within 6 months Active plan of suicide Suicidal ideation with disorganized family
Participants
Moderate to severe symptoms Average depressive episode duration - 72
weeks 27% had at least minimal suicidal ideation at
baseline
Randomization
To 1 of 4 treatments for 12 weeks
1. Fluoxetine alone
2. CBT alone
3. Fluoxetine with CBT
4. Placebo
Randomization
Blinding Independent evaluators
Fluoxetine
6 medication visits x 20-30 minutes Dosage adjusted
Starting dose 10 mg/d Optimum 20 mg/d Maximum 40 mg/d
Mean highest dose 30 mg/d
CBT
15 sessions over 12 weeks x 50-60 minutes Psychoeducation Mood monitoring Increasing pleasant activities Social problem solving Cognitive restructuring Parent and family sessions
Outcome Assessment
Children’s Depression Rating Scale-Revised (CDRS-R)
CGI improvement score (much improved or very much improved)
Assessed at baseline, week 6, and week12
Outcome Assessment
Reynolds Adolescent Depression Scale (RADS)
Suicidal Ideation Questionnaire-Junior High School Version (SIQ-Jr)
All measures reported acceptable psychometric properties
Harm-Related Adverse Event
Harm to self; e.g. cutting Worsening of suicidal ideation Suicidal attempt Harm to others
Suicide-Related Adverse Event
Worsening suicidal ideation Suicidal attempt
Results
Combination of fluoxetine with CBT was significantly superior to placebo fluoxetine alone CBT alone
Results
Fluoxetine alone was superior to placebo CBT alone was not superior to placebo Fluoxetine alone was significantly better than
CBT alone
Response Rate Based On CGI
71% in the fluoxetine with CBT 61% in the fluoxetine alone 43% in the CBT alone 35% in the placebo
Results
Effect size
(CDRS-R)
Effect size
(CGI)
NNT
Fluoxetine
+ CBT
0.980.843
Fluoxetine alone
0.680.584
CBT alone-0.030.2012
Results
“Combination of fluoxetine with CBT is better than fluoxetine alone, which is better than
CBT alone, which is equal to placebo”
Suicidal Behavior in Children Receiving SSRIs
Suicidal ideation decreased in all of the treatment groups
6% of the patients experienced a suicide-related event with no statistically significant difference among the 4 treatment groups
Seven patients made a suicide attempt and there were no completed suicides
Suicidal Behavior in Children Receiving SSRIs
Harm-related adverse events: increased risk (odds ratio = 2.19) for patients receiving fluoxetine compared with those who were not
The odds ratio was higher for fluoxetine alone compared with fluoxetine with CBT.
Protective effect for CBT for suicidal ideation
Summary
Combination treatment with fluoxetine and CBT shows highest efficacy
CBT is a protective factor for suicide in adolescents receiving fluoxetine