Depression in young people

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Editor, – The article by Professor B. Tonge, 'Depression in young people' (Aust Prescr1998;21:20-2), brought to the attention of your readers the recently published National Health and Medical Research Council (NHMRC) guidelines1 about the subject. We thank Professor Tonge for his scholarly summary of the guidelines and would like to make the following comments about physical treatments for this patient group.

Professor B.J. Tonge the author indicates the lack of controlled studies of the newer antidepressants in young people. Since the NHMRC guidelines were released, a large placebo-controlled trial of fluoxetine in depressed children and adolescents has been published2, showing superior efficacy of antidepressant. Professor Tonge mentions the role of lithium, carbamazepine and sodium valproate in treating young persons with bipolar disorder. These drugs - particularly lithium - are sometimes also used to augment antidepressants in unipolar depression. Regrettably, studies of antidepressant augmentation in young people are scarce3,4,5 and restricted to reports of small series of cases. Finally, Professor Tonge makes no mention of electroconvulsive therapy (ECT) in his overview of treatments. Although information about ECT in young persons is limited and ECT is not commonly used in this age group, there is increasing evidence that ECT is a safe and effective treatment for severe depression in teenagers, as in adults.6,7 A total of 42 adolescents received ECT in New South Wales in the period 1990-1995.7 ECT was only given after other treatments had failed. The correlates of good outcome included the psychotic type of depression and absence of personality disorder.

Although some of the above treatments will only be given by specialist psychiatrists, we believe it is important that other practitioners are aware of them.

G. Walter and
J.M. Rey
Child and Adolescent Psychiatrists
Rivendell Unit, Sydney
University of Sydney

Professor B.J. Tonge, the author of the article, comments:
I thank Dr G. Walter and Dr J.M. Rey for providing a pertinent elaboration of my review of the NHMRC guidelines on depression in young people.

They bring attention to the recent study8 of the effectiveness of fluoxetine in the treatment of major depression in children and adolescents. This randomised (stratified for age and sex) double-blind placebo-controlled outpatient study of 96 young people aged 7-17 years with non-psychotic major depressive disorder found significant improvement at the end of the 8-week treatment period in depression rating scale scores and clinical assessment in the group treated with fluoxetine (20 mg morning dose) compared with the placebo group. However, there was no longer-term follow-up of these patients and there was no significant difference between the groups on general psychiatric symptoms (such as school attendance), global functioning and self-reports of symptoms.

Importantly, significant improvements were found for both the group of children aged 12 years and younger, as well as those aged 13 years and older. However, full recovery was unusual with only 31% of the fluoxetine and 23% of the placebo group having only minimal symptoms at the end of the 8-week period. About 8%of the young people receiving fluoxetine discontinued treatment due to the adverse effects of manic excitement for 6% and a severe rash in 2%.

Patients in this study were carefully screened and assessed to conform to strict diagnostic criteria for major depressive disorder (DSM-III-R criteria).The study then used an unusual procedure of placing all patients in a one-week single-blind course of placebo. Those young people who improved and no longer met diagnostic criteria after two weeks were excluded from the study (about7% of the cohort). There is no discussion or justification offered on this procedure of excluding early placebo responders. It is possible that, if this step was omitted and this 7% of cases included in the double-blind placebo-controlled study, then the results may not have demonstrated a significant therapeutic effect compared to placebo.

Therefore, although these findings are encouraging, further replication studies are needed with longer follow-up including measures of global functioning and self-report.

I agree that mood stabilisers such as lithium and sodium valproate have a role in the augmentation of antidepressants in the treatment of severe unipolar depression, but this polypharmacotherapy should be initiated with inpatients or at least by specialist psychiatrists with outpatients. Similarly, ECT has an important but limited role in the treatment of severe, usually psychotic, depression in young inpatients.

Taking the above comments into account, the NHMRC guidelines should still remain the foundation for the contemporary treatment of the majority of young people in Australia who suffer from a depressive illness.